Concurrent Review Nurse

WHO WE ARE:

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE:
This position performs and manages all aspects of case management to include utilization management. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high quality care and cost-efficient outcomes through the process of case management. This position requires excellent communication and diplomacy skills in managing complex working relationships. This is an LPN position.

ESSENTIAL JOB FUNCTIONS:

• Reviews preservice requests routine and urgent and encourage high quality care and to achieve cost effective outcomes.
• Will utilize NCDs, LCDs and MCG to assist in determining coverage of the request.
• Performs concurrent review on all Members that are at an inpatient or observation level of care.
• Will communicate with the facility case manager to assist in discharge planning to appropriate level of care.
• Will ensure all discharge needs are met.
• Interfaces with physician and clinical staff to ensure continuity of care. Works in coordination with case management projects.
• Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG , NCD , LCD and community standards of practice and regulatory developments, and new and experimental procedures).
• Adheres to company and department policies and procedures.
• Communicates with customers, both internal and external, regarding status of referral/referral process. Resources for physician, vendors or contracted providers, regarding benefits.
• Multiple projects under the direction of the utilization department Supervisor.
• Transferring patients from non-contracted to contracted vendors with contract changes.
• Initiation of case management for complex, high utilization members to include identification, assessment of needs, planning and coordination of care, and monitoring of outcomes.
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned

EDUCATION AND EXPERIENCE:
Current LPN or RN license in the state of Oklahoma required.
3-5 years medical/surgical experience required.
Working knowledge of ICD-9/CPT codes

KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of current nursing processes, techniques and established standards, including disease management, medications and community resources
Strong attention to detail
Strong organization and time management skills, including ability to multi-task, learn new skills and reach set goals
Must be able to communicate, both orally and in writing, clearly and effectively
Knowledge of Microsoft Office programs including Word, Excel, and Outlook
Proven ability to work independently or as a member of a team

WORK ENVIRONMENT:
Work is typically performed in an office or other equivalently good environment with rare presence of abnormal variations in temperature or exposure to outside conditions. Physical effort normally found in clerical work or the equivalent. Work is primarily sedentary; however, occasional handling of small objects (up to approx. 10 lbs.), and occasional walking or standing may be required

TRAVEL:
May require limited travel for offsite meetings or training.

SUPERVISORY RESPONSIBILITY:
This position does not have any supervisory responsibilities.

OTHER DUTIES:
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.