Medical Management RN

Location: Cincinnati, OH
Date Posted: 08-31-2018
CONTRACT Medical Management RN – Managed Care
Cincinnati, OH
*** This Full Time, Benefits Available, CONTRACT position is expected to last 4-6 months, or longer! ***
Job Summary:
As a member of the medical management team, the Case Management & Utilization Management RN plays an integral part in the coordination of care assessing the member’s condition and providing them the necessary resources, options, and coordination for a healthy care outcome.  They are primarily responsible for the care management planning and utilization review (concurrent or retrospective) of the member’s care.  The Nurse coordinates and monitors the care of Health Plan members and develops a nursing plan of care.  The Nurse also ensures appropriate level of care through comprehensive concurrent review for medical necessity of outpatient and inpatient care, as well as the utilization of ancillary services, following evaluation of medical guidelines and benefit determination. The Nurse acts as an advocate for members and their families linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward a maximum level of independence. 
Position Description:
The Case Management & Utilization Management RN will serve the daily case management needs of members. This includes administering all provider resources through the care continuum, from the initial referral through discharge and ensuring compliance with the plan of care. They will collaborate effectively with an interdisciplinary team to establish an individualized plan of care for members.  A strong emphasis is placed on Wellness, Disease Management and patient/member education to ensure compliance with the plan of care and prevention of complications with various ailments. The Nurse will develop interventions and processes to assist the Health Plan member in meeting short and long term plan of care goals.  They will coordinate member visits with providers and specialists as needed. 
The Diabetes Case Management & Utilization Management RN will also utilize clinical skills to provide and facilitate utilization review, continued stay reviews, and utilization management of all cases based on clinical experience and recognized guidelines.  Interact with internal and external contacts to determine medical status, type of immediate care needed and future care needs.  Perform Medicare, Medicaid or other sponsoring health benefit organization reviews of members to be cared for in outpatient or acute care settings. They will obtain the information necessary to assess a members’ clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.   As needed, the Nurse will perform prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.   The nurse will make referrals as indicated to complex case management, disease management, or behavioral health; and will collaborate with the disease management, quality management, and other departments in the development of protocols and guidelines designed to standardize care practice and delivery.  The nurse will serve as a backup supervisor/manager for the team, as needed.
Background Profile:
Current unrestricted state Registered Nurse (R.N.) license.
Bachelors of Science in Nursing (BSN) or related field is a plus.
Roughly 3-4 years acute care clinical nursing experience; higher acuity settings (ER, CCU, ICU, OR, etc) preferred.
Around 3-5 years of case management and/or utilization review experience
At least 1-3 years with a managed care organization (Health Plan/ HMO/IPA/Medical Group/TPA/MSO, etc).
Participation in the American Association of Managed Care Nurses preferred.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Knowledge of InterQual criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management.
Strong computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.

The Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health. 
443.552.7423 (CALL – TEXT – FAX)
Schedule a time to talk by clicking HERE

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