CASE MANAGEMENT NURSE

"Possible Work from Home Office"   JOB DESCRIPTION    POSITION TITLE: Case Management Nurse REPORTS TO:  Utilization Management Director STATUS:  Full Time/Exempt   JOB SUMMARY:The Case Management (CM) nurse position is critical to the success of Arcadian Health Plan and as such is responsible for complex case management, research related to Medicare benefit coverage issues and appropriate coding practices related to DRG’s, HHRG’s RUG’s, and general CPT/ICD-9CM coding to ensure appropriate application of billing codes during the authorization process. The Medical Director/Physician Reviewer will identify cases that require intensive case management and refer these cases to the CM Nurse for research and follow-up.  The CM Nurse will work closely with the Medical Director/Physician Reviewer in the management of these complex cases.  Additionally, the Case Management Nurse will provide input to the UMC/QIC meetings and assist in the preparation of meeting materials and reporting requirements. This position is multifaceted; requiring a diverse set of management and organizational skills, as well as clinical expertise.  Additionally, the CM nurse would work closely with our marketing/sales department and be available to assist with presentations to potential Medicare Advantage Beneficiaries.     QUALIFICATIONS: Education:  § Current, valid nursing license (RN) in the state of residence. Ability to obtain valid nursing license in other states that Arcadian Health Plan may enter the Medicare Advantage market. Bachelor of Science Nursing degree preferred.  CCM preferred.  Experience:  § Minimum of 3-5 years of CM experience in an HMO or IPA/PMG setting§ Experience in UMC/QIC meeting preparation, setting agenda’s, keeping minutes§ Minimum of 3-5 year hospital acute care nursing or equivalent§ Experience with computer and software programs (e.g.; Microsoft Word, Excel) and the internet § Experience applying Inter Qual, M&R, or other practice management guidelines preferred§ Experience with case management of the senior/SNP population§ Experience with Medicare billing practices, DRG’s HHRG’s, RUGs, CPT/ICD-9CM coding as it relates to the authorization processes§ Familiarity with Code of Federal Regulations (CFR)§ Familiarity with the CMS website, CMS Manuals, and CMS audits§ Experience giving presentations in front of large groups Â§ Skills:§ Competent administrative and organizational skills, ability to multitask and set priorities§ Effective communication style (written and verbal) with proven ability to positively influence behavior and arrive at a “win-winâ€� resolution§ Strong clinical judgement necessary to interpret and follow medical guidelines.§ Ability to research complex issues as it relates to Medicare benefits and coding/billing practices, synthesize the information, concisely communicate either verbally or in writing findings and recommendations. § Strong computer skills, including the internet, ability to quickly research complex issues and effectively work in a computerized case management system/queue environment with minimal paper § Independent thinker, logical, strategic, with an attention to detail§ Professional demeanor§ Ability to:§ creatively solve problems § develop and write policy and procedures§ implement policies and procedures§ perform data analysis and prepare reports§ prepare training materials and educate providers and office staff§ travel (e.g.; driving to local hospitals, flying)§ assist with sales/marketing presentations Â§ Job Duties and Responsibilities: § Perform complex case management on cases identified by the resource nurse, medical director, physician reviewer or SNP program via phone, fax, email or on-site as needed§ Provide feedback to the medical director/physician reviewer on DRG’s HHRG’s, RUGs, CPT/ICD-9CM coding as it relates to the authorization processes§ Assist Medical Directors in preparing materials for Arcadian Health Plan UMC/QIC meetings§ Oversee the development of a case management program that results in cost efficient utilization of services, continued quality of care and meets federal guidelines.§ Make recommendations for changes to the case management program.§ Review of managedcare.com and all necessary reports.   Physical Requirements of the Position:§ Sitting:  The essential functions of this job are performed while seated at a desk or work station for at least 50% of scheduled work hours§ Standing and walking: The essential functions of this job require the ability to move from one location to another either by walking, driving, or flying.§ Hearing:  Must be able to receive and send detailed information through oral communication and clearly understand people speaking in her/his presence and over the telephone§ Speaking:  The essential functions of this position require speaking and communicating English in a clearly understood voice at all times during scheduled work hours§ Fingering and repetitive motions:  Functions of this position require a fair amount of movements of the wrists, hand, fingers in the use of office equipment such as phones and computer keyboards§ Vision:  The essential functions of this position require the ability to clearly see detailed information via written manuscript and or computer§ Lifting:  A function of this position requires the ability to lift at least twenty-five pounds on an occasional basis§ Availability by phone, fax, or pager when out of the office§ Ability to travel by plane or car Salary:  Starting salary is based on qualifications and experience.  In addition, in accordance with California state requirements, Arcadian does not permit or provide compensation or anything of value to its employees or agents, condition employment of its employee or agent evaluations, and set its employee or agent performance standards, based on the volume of adverse determinations, reductions or limitations on lengths of stay, benefits, services, charges or on the number of frequency of telephone calls, or other contacts with health care providers or patients.   Approved:   Utilization Management Director Date   Medical Director Date