RN Onsite Inpatient Care Manager - Pikeville, KY Job Description Pikeville Medical Center 911 Bypass Road Pikeville, KY 41501 Represents WellCare at assigned facilities to provide concurrent review, discharge planning and coordination and evaluates of members for Case Management needs during face-to-face interaction. Identifies members with high risk medical conditions that will require complicated medical treatments to refer for an individualized post-acute plan of care to reduce the risk of complications and/or re-admissions. Works collaboratively with providers and facilities to coordinate and authorize post-acute care services and will provide referrals to clinical and social support services, including but not limited to, case/disease management, other providers within the plan’s network and with community based resources. Essential Functions: Travels daily to assigned facilities to talk with members and physicians regarding the status and treatments within each case. Based on travel schedule and individual member’s situation, conducts onsite and/or telephonic concurrent review of members in assigned facilities to validate medical necessity of facility admissions. Provides authorization to facilities using standard clinical criteria guidelines in conjunction with clinical judgement to determine the needed care required within the patients individualized created care plan. Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and/or hospitalists, to share information and collaboratively establish acute and post-acute treatment plans for hospitalized members. Interacts with treating physicians and health plan medical directors to evaluate medical treatment plan, and assesses opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care. Documents clinical updates, authorizations and referrals in the health plan medical management system adhering to health plan documentation standards. Utilizing clinical judgement, assesses and evaluates members at risk for complicated medical comorbidities, and/or repeat admissions potential and determines individualized care plan for communication and interventions to promote successful discharge and post-acute care treatment plan. Conducts patient interviews and assessments through personal visits and using clinical judgement determines appropriate level of interventions and assess patient needs for follow up care. Coordinates authorization and/or delivery of post-acute care services, including, but not limited to referrals to case and disease management, home health, medical equipment, skilled nursing facilities and other community based services. Provides members with educational resources to enhance their ability to access health care services, including healthplan contacts, primary care physician and other pertinent health care provider contacts. Facilitates referrals for post-discharge follow up with appropriate professional providers and support services (i.e. transportation) to ensure that members are able to access medically necessary services after discharge. Complies with all health plan and facility based regulations regarding HIPAA and patient safety and security. Identifies quality of care issues, and reports to appropriate healthplan Quality department representative. Performs special projects as assigned. Additional Responsibilities: Nurse will be based out of home, with travel required daily to assigned hospitals and facilities; Frequent travel required to regional healthplan office. Valid driver’s license, without restrictions, is required. Job Requirements Candidate Education: Preferred A Bachelors Degree in a related field Health Services or Nursing Required Associates Degree in Nursing Candidate Experience: Required 3 years of experience in general nursing with exposure in the following: E/R critical care, discharge planning, bedside care, and/or acute care facility. Required 3 years of experience in applying nursing judgement to make clinical decisions with minimal supervisory or oversight Preferred 1 year of experience in Managed Care Candidate Skills: Intermediate Ability to analyze information and covert related activities into a comprehensive work plan Intermediate Ability to work in a fast paced environment with changing priorities Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Ability to effectively present information and respond to questions from families, members, and providers Intermediate Ability to create, review and interpret treatment plans Intermediate Demonstrated written communication skills Intermediate Ability to influence internal and external constituents Intermediate Ability to represent the company with external constituents Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Demonstrated customer service skills Intermediate Knowledge of healthcare delivery Licenses and Certifications: Required KY RN License without restrictions Technical Skills: Required Intermediate Microsoft Excel Required Intermediate Microsoft Outlook Required Intermediate Microsoft Word Required Intermediate Healthcare Management Systems (Generic) Languages: Required English Preferred Spanish
Posted on: Mon, 28 Oct 2013 12:58:16 +0000
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