Position Purpose: This position performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary services requests. Includes medical appropriateness and medical necessity determination requiring considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures and clinical guidelines. Identifies and refers all potential quality and suspected fraud and abuse cases to the appropriate department/associate. Acts as liaison between the beneficiary and the network provider and HN to utilize appropriate and cost effective medical resources. Acts as a resource for training, policy and regulatory/accreditation interpretation.
- Demonstrates regular, reliable and predictable attendance.
- Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.
- Performs research and analyzes complex issues, assesses member needs. Acquires appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy. Accurately applies coding guidelines.
- Summarizes cases including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.
- Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.
- Develops determination recommendations and presents cases to Medical Director when needed.
- Develops and/or reviews appropriate documentation and correspondence reflecting determination. Assures accuracy, completeness and conformance to standards.
- Identifies and refers members who may benefit from disease management or case management and makes appropriate referrals.
- Conducts rate negotiation, when necessary and as per policy, with non-network providers, utilizing appropriate reimbursement methodologies, and documents accurately.
- Actively participates in departmental evaluation, audit and improvement activities.
- Analyzes departmental reports for quality of care, efficiency of services, and cost effectiveness.
- Participates in development of clinical and non-clinical performance improvement projects.
- Performs audits and monitors quality of departmental functions to comply with all standards and other regulatory requirements. Summarizes and provides feedback on audit results, identifies areas for improvement and implements approved recommendations.
- Trains new associates and answers questions related to clinical review services, resolution, correspondence and compliance. Identifies educational opportunities.
- Performs all other duties as assigned.
Education/Experience: Graduate of an accredited nursing program; Bachelor's Degree preferred
• Minimum two years clinical experience
• Three to five years managed care experience, including discharge planning, Case Management, Utilization Management, Home Health, transplant or related experience required
• Health Plan experience preferred
License/Certification: Must have and maintain a current, valid and unrestricted state RN license; UM/CM certification required
NICU experience preferred
UM/CM experience preferred
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Posting ID: 609594817Posted: 2021-03-01