Provides support and execution of programs and tactics used to influence provider and health Plan consumer/beneficiaries behaviors in order to achieve right care in the right place at the right time and the appropriate cost. Plans and provides support for health plan consumers/beneficiaries to align with the objectives of triple aim. This position is responsible to process health plan medical pre-service requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the Medical Management Program Descriptions, and in accordance with all federal and state regulations.
Manages health Plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.
Works collaboratively with both internal and external customers in assisting health Plan consumer/beneficiaries and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.
Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiaries outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
Provides ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence based practices, and all other topics that impact medical management functions.
Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holiday.
Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, MCG, and Hayes.
Requires Registered Nurse (R.N.) licensure in the state of practice. All license or certification must identify the issuing state or entity, type of licensure and expiration date or evidence that the certification is the type that does not expire. A bachelors degree or equivalent experience. Requires proficiency level typically achieved with 5 years of clinical experience. Basic Life Support (BLS) certification is also required.
Must have a working knowledge of care management, acute care and/or home care environments, community resources and resource/utilization management. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format. Must be able to work flexible hours and take rotating call after hours.
Certification(s) related to field, such as Certified Case Manager (CCM), MCG Certification(s), RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN).
Additional related education and/or experience preferred.
Internal Number: 267147
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.