Job Profile Summary
Position Purpose:
Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
Responsibilities
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate
Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Position Purpose:
Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.
- Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
- Contributes to correspondence letter template creation and maintenance with the correspondence team
- Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
- Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
- Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
- Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
- Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
- Performs other duties as assigned
- Complies with all policies and standards
Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
This candidate will be working with the IL and MI Medicaid product, Meridian. Correspondence Team is part Shared Services, which oversees many markets and states. The purpose of the team is to ensure that the members and requesting providers receive the written documentation of a denied service. Candidate may live anywhere in the U.S.
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
Working within a highly engaged team remotely, with ongoing support to produce denial correspondence based off the advisor review that is in easy-to-understand language to the member and adheres to the NCQA and state standards. There may be at times, OT expectations based on business needs. This team does work holidays, which are rotated amongst the team members
Candidate Requirements
Education/Certification
Required: Requires graduated from an accredited school of nursing or A.D. or bachelor’s in nursing
Preferred: 2-4 years of related experience
Licensure
Required: LPN or RN, active in any state
Preferred: Compact
Years of experience required:
Must haves: Minimum 1 year nursing experience. Live anywhere in the U.S.
Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management
Disqualifiers:
Performance indicators: Metric driven in production and quality
- Top 3 must-have hard skills stack-ranked by importance
1
Ability to critically think
2
Ability to effectively use Microsoft OneNote and Word
3
Ability to work remotely, i.e. meet production deadlines; quality metrics
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting
Type of Interviews:
1 teams meeting interview
Required Testing or Assessment (by Vendor):
NO
