Resource Nurse

Resource Nurse ARCADIAN Health Plan Job Title:Resource NurseDepartment:Health ServicesEffective Date: Jan. 2002 (Revised July 2003)Reports to:UM DirectorDirect Reports:NoneFLSA:ExemptJOB SUMMARY:The UM nurse position is critical to the success of Arcadian and as such is responsible for case management (CM), utilization management, and referral management under the direction of the UM Director.  This position is multifaceted; requiring a diverse set of management and organizational skills, as well as clinical expertise.  The UM nurse works closely with the Arcadian providers, the Medical Director, health plan representatives, hospital nurses, home health nurses, physician office staff, Arcadian Service Center staff, and the patients.  The UM nurse is key to ensuring timely and cost effective health care for all Arcadian members.  QUALIFICATIONS:Education:  § Current, valid nursing license (RN/LVN) is required. Bachelor of Science Nursing degree preferred.§ Case Management  Experience:  § Minimum of 5 year hospital acute care nursing or equivalent§ Previous UM or CM experience with HMO, IPA or medical group§ Computer experience (e.g.; Microsoft Word, Excel) and the Internet preferred.  § Experience applying Inter Qual, M&R, or other practice management guidelines preferred Skills:§Competent leadership and administrative skills§Effective communication style (written and verbal) and ability to maintain effective and open communication with all customers, both external and internal§Strong clinical judgment necessary to interpret and follow medical guidelines in authorizing services or making a referral to the Medical Director§Familiarity with computer and the internet§Demonstrated skills in negotiation and problem resolution§Logical, independent thinker §Ability to creatively solve problems §Professional demeanor   Job Duties and Responsibilities: §Perform pre-authorization, concurrent review, and retrospective review for all inpatient and outpatient services, as outlined in the utilization management program§  Make recommendations for changes to the authorization process and list§Knowledgeable with legislative requirements, NCQA guidelines and health plan delegation requirements for utilization management§Confirm patient eligibility§Ensure the denial and appeal process is followed (e.g., determinations for denial are made by the Medical Director, letters are sent with appropriate language and within the correct timeframe)§ Identification of out of area providers for a preferred provider list§ Data entry and appropriate documentation of UM/Case Management activity§ May submit required reports to health plans in a timely manner under the direction of the UM Director§Participate in the case management process that results in cost efficient utilization of services an continued quality of care§Participation in the IPA UM and or QI committee meetings as required§Review of AP reports§Some travel required; a current driver’s license Guidelines for On-site Review at Facilities  The IPA has a mechanism in place to ensure staff, performing on-site utilization management reviews, is in compliance with all Facility requirements during onsite reviews.  This includes hospitals, skilled nursing facilities, and rehabilitation facilities. · When the UM nurse is identified to include onsite review at a facility as part of her job responsibilities, she/he will obtain the individual facility guidelines for identification of staff prior to conducting on-site reviews.· The IPA on-site nurse will follow the facility requirements and notify her UM Director if she is unable to follow the requirements.·If the facility conveys to the IPA on-site nurse that the arrangement is unacceptable to them, the IPA nurse will also notify her UM Director.· The IPA nurse, working in conjunction with the facility, will verify that all facility guidelines have been met.· Guidelines may include, but not be limited to, training and orientation to policies and contracts, display of photo-ID when onsite, proof of current, valid nursing licensure in the state of facility, procurement of a parking permit, and or limited chart access/documentation. 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 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.