Job: Care Coordinator (RN)

This posting has expired and is no longer available.

Browse Similar Jobs: Healthcare - RNs & Nurse Management

Jobing Description

Job Summary

Conducts Medical / Surgical or Behavioral Health medical necessity reviews for continued stay reviews, care coordination, discharge planning, and post-nursing calls. Conducts review and pre-screening reviews for Medical Director prior to non-certification. Initiates discharge-planning care coordination and post-service nursing calls. Utilizes clinical and analytical skills to identify and refers cases to Case Management or Disease Management as appropriate. Provides support to non-clinical staff on clinical and coding questions. Conducts pre-admission screening assessments.
Key Responsibilities

o Coordinates discharge planning, completes necessary authorizations, and conducts post-service nursing calls.
o Conducts Utilization Management continued stay and inpatient reviews to assess medical necessity.
o Researches and collaborates with appropriate community resources to support discharged beneficiaries.
o Prepares more complex cases for Medical Director and Peer Review. Collaborates with Medical Director on decision-making.
o Utilizes clinical and analytical skills to identify and refers cases to Case Management or Disease Management as appropriate.
o Communicates with providers to develop plan of care.
o Conducts complex authorizations for beneficiaries in acute, residential treatment center, skilled nursing facilities, or long-term acute care hospitals.
o Identifies and reports potential quality or fraudulent cases to Internal Audit & Corporate Compliance department or Clinical Quality Management for review.
o Participates in focus group studies as requested, including the development and implementation steps.
o Supports other regional hubs as needed.
o Perform other duties as assigned.
o Regular and reliable attendance is required.

Skills / Requirements

Education & Experience

Required:
o Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state
o 2+ years experience in Medical / Surgical clinical nursing or
2+ years Behavioral Health experience in inpatient or outpatient setting
o Proficiency in medical data entry and Microsoft Word
o Exceptional oral communication skills
Preferred:
o 5 years Medical / Surgical clinical nursing or
Knowledge of Behavioral Health Levels of Care
o 2+ years Managed Care experience
o 1+ year TriWest or TRICARE experience
o Knowledge of Intensity of Service and Severity of Illness indexes; InterQual Imaging Criteria, Procedural Criteria, Level of Care, and Length of Stay; International Classification of Diseases; Current Procedural Terminology; and Health Care Financing Administration Common Procedure Coding System; and American Dental coding
Competencies

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.
Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.
Technical Skills: Thorough knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, and medical management on-line system. Proficient with Intensity of Service and Severity of Illness indexes, InterQual Imaging Criteria, Procedural Criteria, Level of Care, and Length of Stay, Clinical Decision Support Tool, International Classification of Diseases, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract

DoD Statement

You are applying for a position that involves working on electronic systems that have access to Department of Defense ('DoD') systems. Therefore, you must undergo a DoD background investigation. This requires you to submit an application describing the previous 7 years of your life and to provide proof of U.S. citizenship in the form of a certified birth certificate, certificate of naturalization, current passport, form FS-240 or form DS-1350. This process takes several months to complete. During this time, the DoD will grant interim access to U.S. citizens allowing them to work for TriWest until their background investigation is completed. However, the DoD will not authorize interim access for non-U.S. citizens. If you are unable to obtain interim access or pass the background investigation, you are not qualified for this position and TriWest will withdraw any offer of employment or terminate your employment immediately.