Nurse Case Manager

Summary:

Under the direction of the Senior Director of Clinical Review, the Clinical Review Nurse is responsible for complying with the day-to-day operations of the Clinical Review Department. Responsibilities include reviewing, recommending and providing authorization for services requested by providers based on evidence-based medical necessity criteria. The Senior Director of Clinical Review will monitor the Clinical Review Nurse’s activities and outcomes, ensuring compliance with established regulatory and contractual requirements. The position will serve as a liaison between program and its participants and providers.

RESPONSIBILITIES:

–         Processes requests for authorization from in-network providers and communicates in a timely manner when the decision has been made by the Interdisciplinary Team (IDT).

–         Collects, reviews, and evaluates information necessary to reach prospective, concurrent and retrospective decisions using objective evidence-based clinical criteria.

–         Suggests alternate care plans, makes recommendations and coordinates with the Provider/IDT for appropriate utilization of services.

–         Documents case reviews, associated communications, and outcomes in the electronic case file.

–         Presents cases to the site Physician and/or Medical Director for review and determination. Works closely with the Physician and/or Medical Director to ensure that medical review of specific cases occurs timely and meets standards for decision turnaround times.

–         Participates in periodic inter-rater reliability testing on medical necessity criteria application.

–         Recognizes and refers potential quality of care concerns to Quality Management.

–         Maintains confidentiality of all information in compliance with State and Federal Law and program policy.

–         Identifies and communicates system improvements or individual care issues that would cause failure to provide appropriate care or meet service requirements.

–         Performs other duties as assigned.

QUALIFICATIONS:

–   BSN required 

–         Minimum of three to five (3 – 5+) years’ experience in a hospital or home care clinical setting.

–         Knowledgeable about Medicare and Medicaid guidelines.

–         Case Management and discharge planning experience is beneficial.

–         Two to three (2 – 3) years of Utilization Review experience at a Managed Care Organization is preferred.