Medical Case Manager (TCM) - Norristown, PA - Full-time / Part-time

Responsible for providing telephonic medical case management for the Auto TCM Department. Reviews treatments plans based on causality and medical necessity.
 
Primary Responsibilities:

Ensures accuracy, quality and timeliness of reviews are in accordance with NJ regulations and departmental policy and procedures and account protocols
Ensures all notices are accurate and processed timely in accordance with NJ regulations and departmental policy and procedures and account protocols
Reviews and evaluates all medical correspondence received
Identifies that properly submitted treatment plans that qualify for authorization are processed in accordance with NJ regulations and departmental policy and procedures and account protocols
Identifies that properly submitted treatment plans that qualify for a Medical Director Review (MDR) are processed in accordance with NJ regulations and departmental policy and procedures and account protocols
Identifies that properly submitted treatment plans that quality for TCM Negotiation are processed in accordance with NJ regulations and departmental policy and procedures and account protocols
Identifies and recommends Independent Medical Examinations (IMEs), Retrospective Peer Reviews, and referrals to Field Based Case Management (FBCM) as necessary and in accordance with NJ regulations and departmental policy and procedures and account protocols
Identifies approved services appropriate for referral to Cypress Care according to account specific protocols and properly completes the referral according to departmental policy and procedures and account protocols
Reviews the claim treatment history with internal and external contacts in accordance with NJ regulations and departmental policy and procedures and account protocols
Evaluates clinical file and ensures treatment is causally related and medically necessary
Adheres to cost savings measures and departmental and company-wide Quality Assurance programs
Holds to the philosophy and standards of quality as outlined by Procura Management Inc.
Adheres to statutory regulations, HIPPA compliance, account protocols and department policy and procedures
Generates and processes all AIMS correspondence in accordance with NJ regulations and departmental policy and procedures and proofreads to ensure accuracy
Prepares comprehensive summaries following determinations or after significant activity occurs on the file in accordance with departmental policy and procedures and account protocols
Maintains the integrity of RMS system at all times and adheres to all electronic paperless workflows
Attends in-service meetings and continuing education seminars as appropriate
May act as preceptor for TCMs as directed by management
Performs other AIMS Department duties as assigned

Required Qualifications:

Valid RN/LPN license
Proficient computer skills including typing and Microsoft Office software
Excellent communication, interpersonal and organizational skills
Professional phone etiquette
Preferred Qualifications:

2+ years of related case management experience
Understanding of NJ regulations, managed care and insurance terminology
Careers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you'll fill far more than prescriptions. As a member of one of our pharmacy teams, you're empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.(sm)
 
 
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
 
 
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
 
Job Keywords: case manager, medical case manager, RN, LPN, case management, Norristown, Pennsylvania, PA, New Jersey, NJ