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Summary of Responsibilities:
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Provides concurrent and retrospective utilization reviews, large case management, disability case management and other programs to improve the quality of medical care and control costs. Works with minimal supervision and is responsible to make an established range of decisions, escalating when necessary, and updating manager on a regular basis.
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Position Responsibilities:
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- Utilizes clinical experience and appropriate clinical criteria and guidelines, along with Plan provisions, in monitoring, evaluating and coordinating both inpatient and outpatient medical care to promote quality outcomes at reasonable costs.
- Performs prospective and concurrent utilization reviews to determine medical necessity for inpatient admission, inpatient continued stay and selected outpatient services to ensure medically appropriate, high quality and cost effective care and for most efficient utilization of third-party services.
- Assists members (associates, retirees and dependents) in navigating the healthcare landscape and optimizing benefit plan utilization by identifying opportunities to promote quality healthcare.
- Monitors potential high-cost claims for early intervention with case management and retrospectively reviews to assure appropriate and cost effectiveness.
- Communicates regularly with members, physicians, physician office staff, pharmacists and hospital utilization personnel.
- Conducts and coordinates case management activities for non-occupational Short-Term Disability, return-to-work and Family Medical Leave Act cases.
- Keeps management and internal physician consultants informed on an ongoing basis of the status of all large case management cases. Collaborates with management and/or the internal physician consultants on a case-by-case basis.
- Acts as a source of medical information for Benefits Department.
- Keeps up-to-date on current medical trends by regularly reviewing journals and professional publications and attending seminars.
- Documents individual cases for the purposes of cost savings and efficiency analyses and legal record.
- Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality and protection of personal information, including, but not limited to, personal health information and personally identifiable information.
- Provides support as needed for the Company’s occupational nurse and wellness programs.
- Performs other duties as assigned by management.
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Selection Criteria:
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- Demonstrated working knowledge of utilization management principles, including effective use of physician consultants, structure and operation of preadmission review, concurrent review, discharge planning, second opinion, catastrophic case management programs, ACD telephone systems and data collection, analysis and reporting.
- Proven familiarity with the major criteria sets and length of stay guidelines currently used by most systems.
- Demonstrated working knowledge of International Classification of Diseases - 10 codes (ICD-10).
- Proven familiarity with ICD10-CM and CPT-4 coding and DRG-based systems.
- Demonstrated strong knowledge of medical technology, healthcare resources and contemporary trends in the healthcare delivery system.
- Proven experience handling multiple duties and completing assigned tasks accurately and on a timely basis. Must cite examples of proven ability to work independently to schedule and initiate reviews and work with patients, providers and claim processors.
- Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate with all levels of administration, healthcare providers and members in a clear, focused and concise manner. Expected to provide examples of written work such as correspondence, reports, etc.
- Demonstrated high level of customer focus and ability to maintain a positive attitude at all times.
- Demonstrated complete discretion in handling confidential and sensitive materials.
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Work Setting:
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- Works in an office setting and remains continuously in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.
- Frequently moves around the office to access file cabinets, office machinery, etc. While accessing file cabinets, frequently uses upper extremities to reach by extending hands and/or arms in any direction.
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Educational Requirements:
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- Bachelor’s degree in Nursing.
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Computer Skills and Knowledge of Hardware & Software Required:
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- Proficient in word processing and spreadsheet applications.
- Case/claim management system experience a plus.
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Certifications & Licenses (i.e., Series 6 & 63, CPA, etc.):
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- Registered nurse in the state of Ohio.
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Position Demands:
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- Extended hours required during peak workloads or special projects.
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