Rn Care Manager- Utilization Management

Summary of Position:

• Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures. Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Pre/Post Service.
• Provide utilization management as needed to ensure coordination of health care delivery.
• Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post-acute and Care Management. Work with interdisciplinary team to utilize the SNP members' Plan of care to achieve improved health outcomes.
• Support the department’s quality of care and cost containment.

Principal Accountabilities

• Assess and evaluate member’s needs, coordinate care utilizing approved criteria(s). (Include member and family discussion as necessary).
• Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
• Regular attendance is an essential function of the job. Perform other duties as assigned or required.
• Provide appropriate case review; ensure timely notification and correspondence to facilities, members and providers.
• Identify members at risk and refers for Care management and/or disease management as needed.
• Ensure cost effectiveness and identified opportunities to reduce cost are captured (i.e. reinsurance reporting).
• Utilize the member’s contract to determine coverage eligibility. Work with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues.
• Utilize MCG, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
• Refer to Medical Director any questionable quality issues or inappropriate hospitalizations for immediate intervention and/or refer cases that do not meet established criteria for approval of selected procedure or service.
• Prepare and present clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.

Education, Training, Licenses, Certifications:

• MCG Certification preferred.
• Associate degree in nursing; bachelor’s preferred.
• RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
• RN License in the state of New York (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities:

• Managed care experience or Case Management experience.
• Ability to create and execute care management care plans and document per EH’s policies and procedures.
• Ability to work weekends and holidays on a rotating schedule.
• Ability to work remote, EST work schedule.
• Excellent communications skills (verbal, written, presentation, interpersonal).
• 4 – 6 years of clinical experience.
• Ability to speak professionally with all necessary parties associated with the member’s care plan.
• Ability to make appropriate referrals to internal and external programs that meet the member’s needs.
• Ability to: manage a caseload of members in need of care management; and apply the care management process as outlined by the CMSA standards and EH’s policies.
• Effectively able to screen and stratify members who are appropriate for care management services.
• Post-acute facility experience.