POSITION PURPOSE

Responsible for coordinating, processing and managing all in-patient and out-patient claims from a medical standpoint to ensure proper administration of contractual limitations and exclusions to include medical necessity, while maintaining compliance with regulatory guidelines. Responsible for identification of areas for improvement, and formulation of recommendations for solutions. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.

NATURE AND SCOPE

• This role does not manage people
• This role reports to this job: Departmental Leadership
• Necessary Contacts: Healthcare providers, subscribers, BAD, ITS, NASCO, FEP, BMS, and Legal.

QUALIFICATIONS

• Must be a Registered Nurse with a current, unrestricted Louisiana license.
• Bachelor's degree in nursing, business, or related field is preferred.
• CPUR or CPC certification required or must be attained within the first 24 months of hire.
• 3 years of direct patient care/clinical experience to include two years of managed care is required

Skills and Abilities

• Knowledge of standardized code sets and medical terminology is required
• Knowledge of provider and benefit contracts and the ability to interpret and apply the information is required
• Must demonstrate the ability to critically evaluate information making independent decisions and anticipating needs.
• Must demonstrate excellent interpersonal, administrative, and telephone skills.
• Working knowledge of MS Office and other relevant software is required
• Demonstrated ability to handle multiple tasks in customer friendly manner and provide expert support to peers while maintaining performance standards is required

Licenses and Certifications

• Current, unrestricted NursingRN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN license to practice in Louisiana required
• Current, unrestricted NursingRN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN license to practice in states other than Louisiana preferred
• Case Mgmt/Social ServicesCPUR - Cert Prof Util Review must be attained within first 24 months in position.
• Non ClinicalCPC and/or CCSP - Certified Professional Coder must be attained within first 24 months in position.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Responsible for identifying areas of improvement, and identifying and vetting potential solutions with supervisor/manager and implementing solutions in a collaborative manner. May serve as a resource to others and train new staff with oversight of supervisor. May assist with gathering information for unit audits.
• Prepares documentation of medical information, completes research, makes recommendations, and refers potential denials to the Medical Directors and Management when necessary to ensure compliance with URAC standards, MNRO and DOL laws and regulations.
• Completes correspondence correctly when necessary to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.
• Responsible for meeting targets for staff and unit performance as required by company and management standards. Assists supervisor and other units of Care Management maintaining department timeliness standards and participating on cross-department projects.
• Interacts telephonically with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions.
• Utilizes accepted review and LOS criteria in conjunction with appropriate professional nursing judgment to determine medical necessity, accurate length of stay, and discharge needs while maintaining compliance with federal and state regulations and standards. Monitors for, records, and appropriately addresses variances to optimal recovery care path.
• Utilizes appropriate professional nursing judgment in application of contractual benefits and limitations, administrative directives, and claims policy in order to direct the appropriate course of action throughout the continuum of care.
• Assesses and establishes a pertinent plan of care/clinical pathway to support optimal patient outcomes anticipating and preventing avoidable variation in utilization of services. Monitors case progression to ensure compliance with plan or need for re-evaluation and adjustment of plan.

Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.