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Position Is Responsible For Performing Concurrent Review In Accordance With Accepted Department Criteria; Performing Discharge Planning And Identifying Alternate Treatment Programs That Provide Medically Necessary Potentially Cost Effective Services. Consulting With Physicians, Providers, Members, And Other Resources, As Appropriate, To Assess, Plan, Facilitate Implementation, Coordinate, Monitor, And Evaluate Options And Services Required To Meet An Individuals Health Needs, Using Communication And Available Resources To Promote Quality, Cost Effective Outcomes. Serving As Liaison To Physicians, And Members; Serving As Preceptor For Less Experienced Staff. This Position Will Perform Face To Face Visits In San Antonio And Provide Telephonic Support For All Other Locations. Ability And Willingness To Travel Within Assigned Location.

• Concurrent review, discharge planning, and alternate treatment programs. Consult with physicians, hospital UR, Coordinators and hospital discharge planners to determine other resources and appropriate disposition of such cases. May do on-site review of cases.
• Perform additional ongoing functions to support the Medical Management Review, including more than one of the following.
• Apply accepted department criteria to first level reviews for medical necessity and appropriateness for all levels of care as required by group contract.
• Consult with physician, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor, and evaluate options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes.
• Uses professional judgment and departmental guidelines to refer cases to case management and physician reviewers.
• Develop alternate plans and assist members/providers to navigate the health care system optimizing benefits. Refer care options to network providers.
• Assess cases for quality of care and refer cases to the physician advisors for review and follow up.
• Cooperate with other members of the department and interfacing departments as a team to decrease costs, coordinate benefits, and provider services, and quality to subscribers.
• Facilitate second level review of cases not meeting medical necessity guidelines.
• Participate as preceptor for orientation of new employees.
• Maintain and enhance knowledge of clinical nursing and regulatory standards by attending seminars, training sessions, etc.
• Perform Medical Management services for all lines of business, including FEP.
• Practice within the scope of licensure in accordance with URAC and NCQA accreditation standards.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

• Registered Nurse (RN) with current, valid, unrestricted license in state of operations or reciprocity.
• 2 years of clinical experience of direct clinical care to the consumer.
• 1 year experience in health insurance/managed care.
• Customer Service oriented.
• PC proficiency to include Word, Excel, Lotus Notes and database experience.
• Clear and concise verbal and written communication skills.
• Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC. Incumbents with other clinical licenses are not required to obtain multi-state licenses.

PREFERRED JOB REQUIREMENTS:

• 3 years clinical experience.
• Experience in Disease Management.
• Experience in managing complex or catastrophic cases.
• Working toward CM certification or Advanced degree.
• Knowledge of medical management policies and procedures.
• Bilingual in Spanish/English or Polish/English.

#LI-Remote

This is a Telecommute (Remote) role:  Must reside within 250 miles of the office or anywhere within the posted state.

HCSC Employment Statement:

We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

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