RN Case Management

Under the direction of the Director of Utilization Management and Customer Service, this position is responsible to review all referrals for ambulatory care services, elective inpatient services and durable medical equipment. This will be achieved using established criteria and Health Plan benefit guidelines in conjunction with the Medical Director and support staff in the Utilization Management Department. The RN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Responsible for daily processing of retro, prior authorization review and ensuring patient meets appropriate level of care based on appropriate evidence-based criteria. Coordinate the UM process in conjunction with criteria established by Health Plans, CMS, Milliman, InterQual and HPN Clinical Services.
• Apply and follow CMS and Health Plan regulation benefit and criteria hierarchy in regard to requested services.
• Within specific guidelines and procedures; uses clinical knowledge, communication skills, and independent criterial thinking skills towards interpreting criteria, policies and procedures to provide the best and most appropriate treatment, care or services for members.
• Document pertinent information regarding individual referrals utilizing pertinent guidelines established by the health plan, CMS or nationally approved guidelines.
• Serve as clinical liaison for the Utilization Management Department bringing necessary issues or complex cases to the Medical Director and/or UM leadership teams’ attention.
• Collaborate with Medical Director to ensure proper services are approved for our members.
• Demonstrate the ability to research the authorization and claims history.
• Communicate changes with provider referral patters with Medical Director and/or UM leadership team.
• Maintain patient safety and confidentiality following HIPAA guidelines.
• Be available for direct communication with physicians or members in regard to questions regarding the UM process.
• Identify issues within the UM process and provide solution.
• Maintain a positive and team-oriented attitude for the benefit of staff morale.
• Promote and encourage teamwork and pride among staff members regarding UM functions and cultivate good interdepartmental relationships.
• Be aware of changes to UM processes and the possible effects on referral processes.
• Generating of daily aging reports and work with UM staff to ensure daily compliance with regulation turnaround times.
• Maintain a current and accurate knowledge of denial letters and the process followed.
• Work with UM Denial team in developing denial letters for members.
• Communication with Provider Relations team regarding needs for Letters of Agreements when referrals are approved to non-contracted providers.
• Work with Customer Service Department to handle patient and/or provider issues or concerns.
• Attend and participate in staff meeting and in-service learning events.
• HPN Compliance training to be completed annually.
• Language and Cultural Linguistics training completed annually.
• Other duties as assigned.