Job Title
Pay Range: $46.76hr - $51.76hr
Requirement/Must Have
- 5+ years Clinical nursing experience.
- 2+ years Care Management.
- Bachelor's Degree in Nursing.
Responsibilities
- Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
- Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
- Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care.
Nice To Have
- Working knowledge of managed care and health delivery systems.
- Thorough knowledge of clinical guidelines, medical policies and accreditation and regulatory standards.
- Working knowledge of IT and Medical Management systems.
Skills
- Effective written and interpersonal communication skills.
- Strong assessment skills with the ability to make rapid connection with members.
- Ability to work effectively with large amounts of confidential member data and PHI.
- Ability to multitask, prioritize and maintain a dynamic personal organization system.
- Proficient in the use of web-based technology and Microsoft Office applications.
Qualification And Education
- RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire.
- LPN - Licensed Practical Nurse - State Licensure.
- CNS - Clinical Nurse Specialist Preferred.