Concurrent Review Nurse Case Manager
Job Number: 1148
Position Title: Concurrent Review Case Manager
The Concurrent Review Nurse Case Manager is responsible for reviewing requests for Inpatient and Skilled Nursing Facilities services for all plan members. The Concurrent review Nurse works in collaboration with providers and Medical Directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient.
Essential Duties and Responsibilities
- Essential duties and responsibilities include, but are not limited to:
- Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals
- Utilize Miliman Guidelines to assist in determinations of referrals.
- Work with Medical Director(s) when the request does not meet guidelines,
- Knowledge of CMS chapter 13, Condition Code 44, IPPS Final Rule (2 Midnight Rule)
- Meet required by CMS turn-around time (TAT) for referral processing (Expedited and Routine).
- Work with Medical Director issuing NOMNC, IDN using appropriate guidelines and language.
- Initiate single service agreements (SSA) when the required services are not available in network.
- Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
- Monitor Fax Folders, System Queues and Email for incoming requests.
- Verify eligibility and/or benefit coverage for requested services.
- Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
- Contact requesting provider and request medical records, orders, and/or necessary documentation in order to process related pre-service requests/authorizations when necessary.
- Accurately documents referral process and any pertinent determination factors within the referral system.
- Participate in daily clinical rounds with Medical Director presenting new admissions, discussing appropriate Level Of Care (LOS) and discussing daily census,
- Assist with mailing or faxing correspondence to PCP’s, Specialists, related to requests/authorizations as needed.
- Contact members and maintain documentation of call for Expedited requests.
- Recognize work-related problems and contributes to solutions.
- Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
- Maintain confidentiality of information between and among health care professionals.
- Other duties as assigned by Supervisor.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Preferred 1-2 years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations.
- Must of have knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
- High School Diploma or general education degree (GED) and/or training; or equivalent combination of education and experience.
- Certificates, Licenses, Registrations: Registered Nurse (RN) or LVN/LPN required
- Knowledge of Medicare Managed Care Plans
- Word, Excel, Microsoft Outlook
- Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
- Bilingual (English/Spanish) preferred
- Positive, team player attitude
- Excellent relationship management skills
Skills and Abilities
- Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
- Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
- Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution;
- Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
- Report Analysis Skills: Comprehend and analyze statistical reports.
- Transplant knowledge a plus
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Office setting within a medical care center.
- The noise level in the work environment is usually moderate.
- Duties performed primarily telephonically.
Location City: Jacksonville
Location State: Florida
Community / Marketing Title: Concurrent Review Nurse Case Manager
Who is Alignment Healthcare?
- Socially responsible
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- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact email@example.com.