Providing site of service solutions to patients seeking care at non-preferred treatment sites. Providing member with resources to optimize their treatment outcomes. Supporting clinical services such as the appeals program. Skills and Requirements Include: Bachelors: Nursing (Required)
Participate in fair hearings including preparation of justification and evaluation of service determination. Provide training and coaching on documentation and Secondary Reviewer processes. Consult with Medical Director on complex cases to assist with determination of NFLOC's and PCS hours.
Ensuring delivery of medically necessary, appropriate, timely, cost-effective and quality health care services. Supporting health plan operations. Required Skills: Three years of utilization management or discharge planning. Graduate of an accredited school of nursing.
Identify potentially unnecessary services and care delivery settings, and recommend alternatives. Manage network participation, care with specialty networks, care with DME providers. Skills and Requirements Include: 50% Travel required. Prior clinical experience.
Evaluating the pre-service authorization request. Promoting the quality cost-effectiveness of medical care. Forwarding requests to the appropriate physician or medical director with recommendations for other determinations. Qualifications for this position include:
Plan, coordinate, implement, monitor and evaluate the medical services. Coordinate and collaborate services with other care management programs. Skills and Requirements Include: U. S. citizenship. Ability to successfully receive interim approval for government security clearance.
Recommending services for plan members utilizing care alternatives available within the community and nationally. Identifying potentially unnecessary services and care delivery settings and recommending alternatives. Conducting admission review, post-discharge calls and discharge planning.
Performing telephonic clinical triage assessments and utilization management services. Providing health education. Qualifications for this position include: Able to work a variety of shifts: Morning / Mid / Evening and Include Weekends.
Recommend services for plan members utilizing care alternatives available within the community and nationally. Identify potentially unnecessary services and care delivery settings, and recommend alternatives. Conduct admission review, post-discharge calls and discharge planning.
Coordinating the delivery of high quality, cost-effective care based on a customized model of care. Advocating for the member/patient and family among various sites to coordinate resource utilization. Encouraging client/member/patient participation and compliance in the clinical program efforts.