Key skills
CommunicationProblem Solving
About this role
Role Overview
- Participate in activities related to care management program build, implementation, oversight, and delegation.
- Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
- Manage and triage member self-referrals to care management programs.
- Assist members in understanding their available medical benefits and connecting them with in-network providers and community resources.
- Identify barriers preventing the member from meeting maximum quality of life.
- Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
- Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
- Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
- Investigating potential quality of care issues that may affect the quality or safety of the health of members.
- May review medical records and other documentation to ensure quality care.
- Assist in reviewing and updating activities and resources to address member needs.
- Participate in case management and quality committees.
- Assist in reviewing and updating policies and procedures to align with delegated processes.
- Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
- Assist in submission of required documents/policies during application process to accrediting body.
Requirements
- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC)
- Three (3) years of healthcare clinical experience
- Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
- Management of Medicare and/or Medicaid populations.
- Two (2) years Care Management experience.
- Working Knowledge of InterQual and/or Milliman Care Guidelines
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning
- Excellent written and oral communication
- Problem solving capabilities to drive improved efficiencies and customer satisfaction
- Attention to detail
- Proficiency with Microsoft Office
Benefits
- Remote for day-to-day but will have rotations on-site (Morgantown, WV) at Peak Welcome Center
- Standard office environment