Rn Comprehensive Care Management

at Highmark Health in Boise, Idaho, United States

Company :

Highmark Inc.

Job Description :

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.

1. Performs a complete review for medical necessity, pre service, post service, or concurrent, using criteria, medical policy and submitted medical information, with Medical Director review as indicated. The RN will complete the appropriate notification processes.

2. Demonstrates the ability to triage incoming calls for urgency and comply with regulatory processes. Depending on the type of request, the RN must possess the knowledge of applying the appropriate timeframes to the request and meet those timeframes for requesting medical records or sending out the decision of the request. Along with the timeframes, when requesting records, the RN must demonstrate the ability to be compliant with HIPAA (Health Insurance Portability and Accountability Act) on the information being requested.

3. Provides cost effective claim negotiation services with out-of-network (OON) providers for precertified medically necessary health services, in coordination with the client, and as per plan provisions.

4. Facilitates and provides adverse determination case appeal reviews as requested, and as appropriate, based on a member's appeal rights, plan provisions and applicable regulatory guidelines.

5. Acts as an advocate and liaison to meet a member's individual health care needs, the RN will assess, plan, implement, coordinate, monitor and evaluate options and services. This is accomplished by using communication and available resources to educate the member and to promote quality, cost-effective.

6. Exhibits and applies clinical understanding of the medical diagnosis (es), case and disease management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals.

7. Exhibits and applies clinical understanding of the medical diagnosis (es), case and disease management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals.

8. Performs other related duties as requires.

Education/Experience/Skills Requirements

Required Education:

Associates Degree: Nursing

Preferred Education:

Bachelors Degree: Nursing

Required Experience:

3 years clinical experience, 1 year of which must be in a hospital setting. Multi-state RN licensure preferred. Bilingual ability preferred, fluent in Spanish.

Required Knowledge/Skills:

1. Excellent time management skills with ability to multi-task

2. Excellent organizational skills and attention to detail

3. Excellent verbal and written communication skills

4. Strategic thinking/planning/problem-solving skills

5. Ability to work effectively with minor supervision, independently and with the team

6. Must be able to work in a fast-paced environment with daily work processing deadlines

7. High degree of business maturity and demonstrated confidentiality, HIPAA compliant

8. High energy level and ability to project enthusiasm

9. Persuasive communication style

10. Polished, professional image and reputation

11. Demonstrated personal accountability

12. Excellent computer skills with ability to work in multiple software programs including MS Word, MS Excel, MS PowerPoint, MS Access, Visio

13. Knowledge/experience in all aspects of Care Management and the health insurance industry

14. Knowledge/experience in medical management of self funded (ASO) health plans desired

15. Experience with claim review, ICD-9, CPT coding preferred

16. Stop-loss claim experience desired

Required Licenses/Certifications:

Registered Nurse

CCM (Certified Case Manager) designation required within 3 years of accepting position.

Problem Solving

Managerial/Supervisory Responsibilities

Does this Position have Supervisory Responsibility? No

Number of Emps Supervised:

Titles of Employees Supervised:

Financial/Budgetary Responsibilities:

Other Job Specifications:

External Contacts:

Working Conditions/Physical Demands:

Position requires:

• Must be able to work in an office environment

Position involves:

• Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks

• Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)

Pay Range Minimum:

$57,700.00

Pay Range Maximum:

$106,700.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

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Req ID: J222657