case management nurse

US Department of Veterans Affairs

DoD Case Management Program Nurse Manager

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
 <li>
 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
 </li>
 <li>
 Review various types of services, including but not limited to:
 </li>
 <li>
 Transplants
 </li>
 <li>
 Air Ambulance
 </li>
 <li>
 Chemotherapy
 </li>
 <li>
 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
 <li>
 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
 <li>
 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
 <li>
 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
 <li>
 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
 </li>
 <li>
 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
 </li>
 <li>
 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

Matrix Providers

Matrix Providers is hiring a Registered Nurse - Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Buckley AFB, Aurora, CO. Employment Status: Full Time Compensation: $36.57 - $51.96 per hour Benefits: Competitive financial package with a comprehensive insurance package including health, dental, vision, and life coverage. Accrued Paid Time Off (PTO) Paid Holidays (Outlined in Handbook) 401(k) Plan Minimum Requirements Registered Nurse (RN) Utilization Management: Degree/Education: Bachelor&rsquo;s degree in nursing. Certifications: Basic Life Support Certified/certification eligible in relevant specialty such as: Certified Managed Care Nurse through the American Board of Managed Care Nurses; Certification in Health Care Quality and Management (HCQM) through American Board of Quality Assurance and Utilization Review Physicians (ABQARP) Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center Utilization Management Accreditation through National Committee for Quality Assurance (NCQA) are desired. Experience: A minimum of 36 months total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 12 recent consecutive months within the last 12 months. Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse. Overview: Serve as a key member of the Utilization Management team, providing comprehensive support to TRICARE beneficiaries. Function independently to ensure appropriate, cost-effective healthcare delivery within TRICARE and Military Health System (MHS) guidelines. Key Responsibilities: Manage a robust Utilization Management program, conducting reviews (prospective, concurrent, retrospective) to ensure proper use of patient care services. Analyze trends, identify inefficiencies, and recommend process improvements to optimize patient care at appropriate levels. Coordinate with military and civilian providers to ensure services meet medical necessity, cost-effectiveness, and TRICARE standards. Serve as a resource for primary care managers, interpreting guidelines, monitoring referrals, and optimizing MTF and civilian healthcare services. Identify and address access/utilization challenges, including enrollment, procedures, inpatient admissions, claims, and grievances. Conduct systematic monitoring and evaluation of utilization metrics, identifying areas for improvement and reporting findings. Provide training to healthcare providers on referral practices for quality and cost-effective care. Qualifications: Advanced knowledge of TRICARE, MHS policies, and referral management systems. Strong analytical skills with the ability to interpret data and recommend solutions. Experience with Electronic Health Records (MHS Genesis preferred). Interpersonal skills to collaborate effectively with diverse teams and stakeholders. Desired Skills: Familiarity with government regulations, healthcare financing, and quality/risk management. Proficiency in office automation software and DHA-approved documentation systems. This role supports healthcare excellence by optimizing resources, improving care quality, and ensuring compliance with TRICARE and DHA standards. We support our employees with an accessible dedicated representative to assist you throughout the duration of your contract. We firmly believe that a healthy work/life balance enables you to perform at your best. Our mission is to serve America&rsquo;s military family by aligning exceptional healthcare workers like you with rewarding career opportunities. Come home to Matrix. #INDKK

Registered Nurse - Utilization Management

Kaiser Permanente

<div>** LICENSED PRACTICAL NURSE - EPRO - TRANSPORTATION HUB - MUST LIVE IN WA OR ID **
PER DIEM OPPORTUNITY - MONDAY-SUNDAY - HOURS: 5PM-8AM
Prior ER/ED, Case Management, UM/UR, Emergency Transportation Exp. a Plus! (Open to Patient Triage/Phone Nursing Experience)<div>
Job Summary:</div><div>
Provide direct and indirect nursing care to patients in routine nursing situations, under the direction and supervision of a registered nurse or licensed physician. In complex situations in which the patient is unstable or requires urgent or emergent care, the LPN functions under the direct supervision of the RN or licensed physician. The LPN is an integral member of the Health Care team, participating in patient assessment and the formulation, implementation and monitoring of the care plan.</div><div>
</div><div>
If part of the Infusion Therapy department - this position provides Infusion Therapy to Kaiser Foundation Health Plan of Washington members including blood transfusions, IVIG, hydration, antibiotics, etc. Also may facilitate and coordinate care for members with oncologic diagnoses</div><div> 

Essential Responsibilities:</div><ul><li>
Assessment: Assists in the assessment of patient/consumer need for care and communicates with RN/MD providers appropriately and in a timely manner. Determines patient/consumer purpose for admission/visit. Collects data relevant to visit/admission, ongoing care as directed by standards/plan of care. Recognizes urgent/emergent situations and appropriately refers/manages.</li><li>
Plan of Care: Contributes pertinent information to the plan of care and assists in monitoring care. Delivers nursing care as determined by plan or patient needs. Recommends modifications in plan of care as needed. Assist patients/families in self care activities. Demonstrates understanding of the physiologic and psychological effects of normal aging by assessing and implementing care to meet the needs of populations served. Implementation: Provides nursing interventions safely and competently and reports relevant findings to RN/MD in timely manner. Follows through and implements plan of care as directed; a) provides appropriate instruction to patient/consumer about routine health maintenance, normal/abnormal lab results, special procedures and follow-up care as directed; b) prepares and administers approved medications at the direction of the RN and upon order from MD, ARNP, or PA; c) performs treatments and assists with procedures as directed; d) competently performs skills/tasks as listed on LPN skills competency inventory.</li><li>
Evaluation: Assists in evaluating patient/consumer response to care through communication and observation. Recommends modifications in plan of care to RN/MD/ARNP/PA based upon patient/consumer response.</li><li>
Age Specific Care: Demonstrates understanding of the physiologic and psychological effects of normal aging by assessing and implementing care to meet the needs of those populations served. Reports appropriate age-specific assessment findings to the RN. Demonstrates effective communication skills with those specific age populations served.</li><li>
Communication and Coordination of Care: Communicates and cooperates with other health care team members in planning and implementing care. Reports appropriate age-specific assessment findings to the RN/MD/ARNP/PA.</li><li>
Demonstrates effective communication skills with those specific age populations served.</li><li>
Orientation: Orients patients/consumers to the health care team members, the services available, and the means of access to those services. Demonstrates an awareness of the Consumer Bill of rights and Responsibilities. Participates in the orientation of new consumers to KFHPWs policies and procedures.</li><li>
Instruction: Assists in the identification of educational needs and communicates to RN/MD in timely manner. Instructs patients/consumers according to the educational plan of care or appropriate educational materials. Encourages patient/consumer compliance with therapeutic nursing and medical regimens.</li><li>
Preventative Care: Identifies patient consumer risk factors. Utilizes available health education resources for preventive care. Reinforces the plan of care to improve general health status. Promotes patient/consumer self-care responsibility for meeting their own health needs</li><li>
Documentation: Records accurate and pertinent data on the medical record according to documentation guidelines.</li><li>
Safety/Comfort: Provides a safe environment for each patient consumer and adheres to KFHPW/facility/unit specific safety standards. Adheres to KFHPW infection control, safety hazardous waste, universal precautions, and CPR standards.</li><li>
Professional Development: Identifies own learning needs and participates in educational efforts to meet those needs. Identifies own learning needs related to those age-specific populations served and participates in appropriate educational programs. Participates in staff orientation and student education activities. Participates with managers and peers in completing the process for self and colleague/team performance reviews. Consistently demonstrates an appearance consistent with KFHPW dress code policy. Participates in activities related to QA/QI,work redesign, and cost-saving measures.</li></ul><div> 
Basic Qualifications:</div>
<div>Experience</div> 
 
<ul><li>N/A</li></ul><div>
Education</div> 
 
<ul><li>Degree from an accredited program.</li></ul><div>
License, Certification, Registration</div>
<ul><li>Practical Nurse License (Washington) required at hire OR Compact License: Practical Nurse required at hire
</li></ul><ul><li>Basic Life Support required at hire 
</li></ul><div>
Additional Requirements:</div> 
<ul><li>
N/A</li></ul><div>
Preferred Qualifications:</div> 
 
<ul><li>Recent ambulatory care experience.</li><li>
Knowledge of electronic patient charting systems.</li></ul> 
PrimaryLocation : Washington,Renton,Renton Administration - Rainier 
HoursPerWeek : 1 
Shift : Night 
Workdays : Mon, Tue, Wed, Thu, Fri, Sat, Sun 
WorkingHoursStart : 05:00 PM 
WorkingHoursEnd : 08:00 AM 
Job Schedule : Call-in/On-Call 
Job Type : Standard 
Employee Status : Regular 
Employee Group/Union Affiliation : J02|SEIU|SEIU Local 1199 Service Unit 
Job Level : Individual Contributor 
Job Category : Nursing Licensed &amp; Nurse Practitioners 
Department : Renton Admin Rainier - Emergency-Case Management - 1130 
Travel : No 
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.</div>

LPN - EPRO Transportation Hub - Per Diem Must Live in WA/ID

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
 DLcZRrpbP4
</div>

Utilization Management Nurse

Included Health

<div>
 We're looking for a Newborn/Pediatric Nurse Care Manager for our Care and Case Management team, who is passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions. The telephonic Nurse Care Manager will guide members through complex Medical and Behavioral Health situations, partnering with a diverse clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in a creative way. The Nurse Care Manager should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as an advocate. You should also excel at creating cohesive care plans, and should have the clinical skills to guide members clinically and navigate available benefits and resources. Nurse Care Managers will support members through complex care management, disease management, and acute case management, ensuring they receive longitudinal care that results in excellent health outcomes.
 
 
 
 Schedule: Monday-Friday 9am-6pm PST
 
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Deliver coordinated, patient-centered virtual Care Management by telephone and video that improves members' health outcomes.
 </li>
 <li>
 Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals.
 </li>
 <li>
 Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general.
 </li>
 <li>
 Partner with the members' local providers to ensure coordinated care.
 </li>
 <li>
 Provide compassionate, longitudinal follow-up care, building supportive relationships.
 </li>
 <li>
 Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.
 </li>
 <li>
 Coordinate necessary resources that holistically address members' problems, whether clinical or social
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 Bachelor of Science in Nursing (BSN).
 </li>
 <li>
 Must have current CCM Certification or eligibility within 6 months of hire
 </li>
 <li>
 5+ years of experience in nursing
 </li>
 <li>
 2+ years experience working in care management
 </li>
 <li>
 Must reside in a compact NLC state.
 </li>
 <li>
 Active Compact RN license in good standing with the nursing board of their state.
 </li>
 <li>
 Willingness to become (and maintain) licensure in multiple states.
 </li>
 <li>
 Work 9AM-6pm PST (Preference for those based in MST/PST time zones)
 </li>
 <li>
 Be comfortable discussing several medical conditions and experience with populations across the age ranges
 </li>
 <li>
 Spanish speaking desirable
 </li>
 <li>
 Experience working remotely, and strong competence and ability to use multiple computer/medical record systems.
 </li>
 <li>
 Be empathetic. We work with patients and their families who are going through challenging times. You practice empathy and reassure patients that we are available to help them.
 </li>
 <li>
 We are a fast-growing company and we are busy. Our team will meet volume goals without sacrificing quality.
 </li>
 <li>
 Strictly follow security and HIPAA regulations to protect our patients' medical information.
 </li>
 <li>
 Be pleasant, responsive, and willing to work with and learn from our team.
 </li>
 <li>
 A lot of time is spent on the phone with patients and families, and a lot of time communicating with colleagues. Therefore, the ability to gather a clinical history, answer questions at a patient level, and summarize findings is critical.
 </li>
 <li>
 Efficient at writing medical information in easy-to-understand, patient-centric language.
 
 
 </li>
 </ul>
 The United States new hire base salary target range for this full-time position is:
 
 
 $73,700 - $103,180 + equity + benefits
 
 
 This range reflects the minimum and maximum target for new hire salaries for candidates. Below is additional information on Included Health's commitment to maintaining transparent and equitable compensation practices across our distinct geographic zones.
 
 
 Starting base salary for the successful candidate will depend on several job-related factors, unique to each candidate, which may include, but not limited to, education; training; skill set; years and depth of experience; certifications and licensure; business needs; internal peer equity; organizational considerations; and alignment with geographic and market data. Compensation structures and ranges are tailored to each zone's unique market conditions to ensure that all employees receive fair and competitive compensation based on their roles and locations.
 
 Your Recruiter can share your geographic zone alignment upon inquiry.
 
 
 
 In addition to receiving a competitive base salary, the compensation package may include, depending on the role, the following:
 
 
 Remote-first culture
 
 
 401(k) savings plan through Fidelity
 
 
 Comprehensive medical, vision, and dental coverage through multiple medical plan options (including disability insurance)
 
 
 Full suite of Included Health telemedicine (e.g. behavioral health, urgent care, etc.) and health care navigation products and services offered at no cost for employees and dependents
 
 
 Generous Paid Time Off ("PTO") and Discretionary Time Off ("DTO")
 
 
 12 weeks of 100% Paid Parental leave
 
 
 Family Building Benefit with fertility coverage and up to $25,000 for Surrogacy &amp; Adoption financial assistance
 
 
 Compassionate Leave (paid leave for employees who experience a failed pregnancy, surrogacy, adoption or fertility treatment)
 
 
 11 Holidays Paid with one Floating Paid Holiday
 
 
 Work-From-Home reimbursement to support team collaboration and effective home office work
 
 
 24 hours of Paid Volunteer Time Off ("VTO") Per Year to Volunteer with Charitable Organizations
 
 .
 
 
 
 
 About Included Health
 
 
 
 Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We&rsquo;re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community &mdash; no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It&rsquo;s all included. Learn more at
 
 includedhealth.com.
 
 
 
 Included Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law. Included Health considers all qualified applicants with arrest or conviction records in accordance with the San Francisco Fair Chance Ordinance, the Los Angeles County Fair Chance Ordinance, and California law.
 
 
 Included Health uses AI-assisted tools at select stages of the hiring process to enhance efficiency, consistency, and communication. AI does not make hiring decisions&mdash;final decisions are made exclusively by our recruiting and hiring teams.
</div>

Pediatric Nurse Care Manager

Connecticut Children's

<div>
 
 Job Description
 
 
 
 
 Applicants must be residents of Connecticut, Massachusetts, or New York to be considered for this position.
 
 
 
 
 The Center
 
 
 
 Connecticut Children&rsquo;s Center for Care Coordination (The Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children, but enhances the care giving capacity of families. This team reports to The Center for their leadership.
 
 
 
 Position Details
 
 
 
 The Portal of Entry Utilization Management Nurse (POE) has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. The candidate should possess a working knowledge of medical necessity tools such as InterQual&reg; and Milliman Care Guidelines&reg; and be proficient in medical record reviews. This individual supports the Care Management program by developing and/or maintaining effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. The purpose of the POE is to support the physician and other qualified practitioners in determination of defensible patient class at the time of admission in the ED. The POE serves as a resource to all members of the health care team on defensible patient status and promotes effective utilization of hospital resources.
 
 
 This individual maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements. The POE nurse will function in accordance with facility policies and processes. This individual will support process improvement activities and report key metrics to facility leadership as requested. audiences. The POE Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The POE Nurse participates and provides support to the hospital&rsquo;s Utilization Management Committee. They collaborate with multiple leaders at various levels throughout the organization. This is an on-site role interfacing with the admitting physician on cases to support industry-accepted level of care criteria.
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews based on appropriate guidelines. Uses these criteria to screen for defensible level of care based on medical record documentation. Escalates cases as appropriate for secondary review. -15%
 </li>
 <li>
 Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -15%
 </li>
 <li>
 Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -10%
 </li>
 <li>
 Performs and documents initial / admission medical necessity review for all points of entry. -10%
 </li>
 <li>
 Communicates initial medical necessity review results with emergency department and admitting providers as necessary to support defensible admission status orders. -10%
 </li>
 <li>
 Proactively collaborates with emergency department providers and staff to identify patients likely to require hospitalization. -10%
 </li>
 <li>
 Works in conjunction with emergency department social workers and other staff to identify and secure available and necessary services to support clinically appropriate hospital admission avoidance. -3.0%
 </li>
 <li>
 Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary. - .5%
 </li>
 <li>
 Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5%
 </li>
 <li>
 Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -.5%
 </li>
 <li>
 Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.5%
 </li>
 <li>
 Pre-Admission Reviews -15%
 </li>
 <ul>
 <li>
 Performs prospective medical record review of patients scheduled for outpatient/inpatient procedures scheduled in the hospital setting.
 </li>
 <li>
 Works in collaboration with Finance to identify the appropriate setting for scheduled admissions, procedures, and medication administration by reviewing pertinent clinical information and collaborating to obtain prior authorization when necessary.
 </li>
 <li>
 Screens scheduled patients to ensure that they are scheduled in a defensible utilizing industry-accepted level of care criteria.
 </li>
 <li>
 Is able to review and interpret the patient&rsquo;s medical record to supply appropriate information to third-party payers as necessary.
 
 
 
 </li>
 </ul>
 </ul>
 Additional Responsibilities -5%
 
 
 <ul>
 <li>
 Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children&rsquo;s patients.
 </li>
 <li>
 Assist with discharge planning as necessary to coordinate the right care, in the right setting and the right time for CT Children&rsquo;s patients.
 </li>
 <li>
 Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources
 </li>
 <li>
 Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system.
 </li>
 <li>
 Commitment to ONE TEAM Culture. -2.5%
 </li>
 <li>
 Performs other job-related duties as assigned. -2.5%
 
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 Education and/or Experience Required:
 
 
 
 <ul>
 <li>
 Education: Bachelor of Science in Nursing (BSN)
 </li>
 <li>
 Experience: 3 years of nursing experience in a healthcare setting
 
 
 
 </li>
 </ul>
 
 Education and/or Experience Preferred:
 
 
 
 <ul>
 <li>
 Experience:
 </li>
 <ul>
 <li>
 Pediatric nursing experience
 </li>
 <li>
 Previous experience in Utilization Review
 </li>
 <li>
 Previous experience in Case Management or Discharge planning
 
 
 
 </li>
 </ul>
 </ul>
 
 License and/or Certification Required:
 
 
 
 <ul>
 <li>
 State if Connecticut Nursing License.
 
 
 
 </li>
 </ul>
 
 License and/or Certification Preferred:
 
 
 
 <ul>
 <li>
 Case Management Certification.
 
 
 
 </li>
 </ul>
 
 Knowledge, Skills and Abilities:
 
 
 
 Knowledge:
 
 
 <ul>
 <li>
 Demonstrate working knowledge of how to interpret and apply medical care criteria.
 </li>
 <li>
 Knowledge of community resources, treatment options, home health availability, funding options and special programs.
 
 
 
 </li>
 </ul>
 Skills:
 
 
 <ul>
 <li>
 Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards
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 <li>
 Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
 </li>
 <li>
 Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC.
 
 
 
 </li>
 </ul>
 Abilities:
 
 
 <ul>
 <li>
 Self-directed/motivated, organized, diplomatic and team-oriented.
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 <li>
 Function in a high energy, fast moving environment.
 </li>
 <li>
 Maintain flexibility as determined by acuity of medical unit.
 </li>
 <li>
 Prioritize case load.
 </li>
 <li>
 Collaborate with various disciplines.
 </li>
 <li>
 Communicate effectively and efficiently.
 </li>
 <li>
 Prioritize and manage multiple tasks.
 </li>
 <li>
 Excellent written and verbal communication skills.
 
 
 
 </li>
 </ul>
 
 About Us
 
 
 
 Connecticut Children&rsquo;s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children&rsquo;s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.
 
 
 At Connecticut Children&rsquo;s, treating children isn&rsquo;t just our job &ndash; it&rsquo;s our passion. As a leading children&rsquo;s health system experiencing steady growth, we&rsquo;re excited to expand our team with exceptional team members who share our vision of transforming children&rsquo;s health and well-being as one team.
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Portal of Entry (ED) Utilization Management Nurse- 32hr- Onsite

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