Behavioral/Mental Health Um/Br Coordinator, Case Management

Imagine360 is currently seeking a Behavioral / Mental Health UM/BR Coordinator, Case Management to join the team! The UM/BR Nurse Coordinator, Case Management role is responsible for providing utilization review/benefit review and care coordination activities. By continuously reviewing and auditing patient treatment files, the UM/BR Nurse Coordinator will ensure that health care services are administered with quality, cost efficiency, and within compliance. Our ideal candidate will have previous Behavioral / Mental Health, RN experience.

Position Location: 100% Remote

Responsibilities include but are not limited to:

• Identify, collect, process, and manage data to complete reviews for medical necessity per Medical Management approved clinical guidelines.
• Concurrent review of patient's clinical information for efficiency.
• Ongoing review of precertification requests for medical necessity.
• Coordinates patient's discharge planning needs with the healthcare team internally and externally.
• Employ effective use of knowledge, critical thinking, and skills to:
  • Advocate quality care and enhanced quality of life.
  • Prevent patient complications during hospital stay.
  • Advocate decreased hospital stay when appropriate.
• Collaborate with Case Managers to identify member needs and proactively create review cases.

• Staff complex cases with Team Lead and/or Supervisor, Case Management.

• Complete the utilization review and benefit review process per policies and procedures.
• Accurate utilization and documentation in appropriate software including time slips in, to complete and document the review process per policies and Procedures.
• Consult with Medical Management Physician Advisor or peer reviewer per policy and procedures.
• Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure.
• Assess and review current treatment history to identify appropriate referrals to other Medical Management Services.
• May carry a case load of patients and perform essential activities of Case Management.
• Attend and participate in team meetings, trainings, and other job specific events as required.
• Work in an intensive, fast-paced environment with minimal supervision
• Ability to stay organized and interact well with others in any situation.
• Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed.
• Communicates professionally and effectively.
• Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and Procedures.
• Complete HIPAA and URAC Training Annually.
• Perform all tasks in accordance with HIPAA/PHI guidelines.
• Appropriately escalate difficult issues.
• Complete duties in accordance with scope of licensure and certifications held or requested.
• Perform other duties and projects, as assigned.

Areas of Responsibility Scope of Practice:

• In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making. The scope of practice includes, but is not limited to:

• • Evaluating clinical data
  • Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines,
  • Coordination of treatment plans, interventions, and outcome measurement
  • Rationale for the effects of medication and treatments
  • Accurately report:
    • Administration of medication and treatments
    • Contact with other health care team members.

• Respect the client's right to privacy by protecting confidential information.

• Promote and participate in education and counseling to a participant based on health needs.
• Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.

Required Experience / Education:

• Nursing degree from an accredited college, university, or nursing school.
• 1+ years in Utilization Review or transferrable nursing experience and skills.
1+ years in Case Management or transferrable nursing experience and skills.

Preferred Experience / Education:

• Experience working with MCG and NCCN guidelines.
• Experience working in a URAC accredited Case Management program preferred.
• Experience working within an insurance agency or TPA experience specializing in employee benefits and self-funded medical plans.

Skills and Abilities:

• Ability to work independently in a home office environment.

• Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet.
• Ability to resolve problems independently and demonstrate ability to multi-task.

• Strong written, oral, and telephonic communication skills.

• Strong presentation skills.
• Ability to demonstrate a commitment to building new skills and fostering a positive work environment.

• Demonstrated organizational skills, problem-solving, analytical skills, and detail oriented.
• Demonstrated ability to prioritize workloads, multi-task, and manage priorities to meet deadlines.
• Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations.

Licenses or Certification:

• An active unrestricted Registered Nurse License in eNLC compact state. Must maintain CEUs as required by applicable State Board(s) of Nursing and required certifications. Must be willing to obtain and maintain additional license as required to perform the job functions of the organization.

What can Imagine360 offer you?

• Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
• 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**