RN active Must have Acute care in background ( 2 years )Outside the box thinker to work with clients and claimsCompany will train to be a Case Manager: training in person in IndyTeam of RN Case Managers works closely togetherOn call rotations one every 6-7 weeks works from home when on callMaybe remote later but not right now. All training in person at home office. Plan on being at the home office for the future until more seasoned.Company paid Parking as they are located across from the Indianapolis Children’s Museum.
- Bachelor of Science in Nursing is preferred but not required
- Experience in utilization review, case management, or large case management functions with a managed care or insurance company preferred
- Experience with auditing medical charts against itemized medical bills.
- Certified Case Manager preferred (CCM)
- Proficient verbal and written communication skills in a foreign language a plus
- Active membership in a professional association related to nursing a plus
- Comprehensive benefits package including Medical/RX/Dental/Vision insurance
- 401k Plan with company match
- On site fitness center
- Casual dress environment
- Tuition reimbursement plan
Job RequirementsDUTIES AND RESPONSIBILITIESPerform Certifications, Concurrent Reviews, Retrospective Reviews, Medical Evacuations, and Large Case Management.Determine and develop case management care plans with short and long-term goals that are action oriented and time specific designed to meet the insured’s needsMonitor treatment, outcomes and care plan, suggesting alternate care settings when appropriate and evaluating and updating goals as neededAct as an advocate and provides ongoing health education when necessary.Knowledge of Non-certification process and Appeals process including logs and time frames.Review medical services for medical necessity.Direct and/or re-direct members to in-network providers.Negotiate discounts with out of network providers.Direct healthcare team members to utilize alternative care settings when appropriate.Identify potential large case management cases by diagnosis, dollar amount and/or high utilization of medical services.Review medical information for large case management.Consult medical criteria and other medical resources as needed.Document information and status in ACM systems and documents.Participate in the on-call rotation schedule.Prepare precertification and/or case management reports as needed.Use good judgment when evaluating medical cases and confer with Medical Director when appropriate.Communicate with other members of team as needed, and ensure that information is shared appropriately.Maintain confidentiality and privacy of all protected health information.Remain current on regulations and legislation that affect utilization review functions.Continue education through relevant reading materials, online courses and/or seminars.Support and participate in Quality Management activities.Utilize clinical support tools as indicatedMaintain a working knowledge of the Core and Utilization Management standards established by URAC and any applicable state or federal regulations as appropriate for job dutiesReport/document complaints when/if receivedAny other job duties or tasks as assigned.
- Active State of Indiana license as a Registered Nurse in good standing
- Minimum two (2) years of acute hospital-based experience providing direct patient care
- Experience using medical criteria as an aid to decision-making
- Good computer skills including working knowledge of the Internet and Microsoft Office (e.g. Word and Excel)
- Excellent customer service skills and phone etiquette.
- Excellent organizational skills and attention to detail.
- Excellent written and oral communication skills – Must be able to express ideas clearly, concisely, and logically. Must make effective and persuasive arguments when discussing medical care issues while representing a positive, professional image of the company
- Initiative – proactive in resolving problems, reporting discrepancies, suggesting new ideas and seeking process improvements.
- Judgment – use of good clinical judgment as it relates to medical treatment in case management.
- Flexibility – must be willing to adjust as the industry or job requirements change.
- Teamwork – must work well in a team and help foster a cooperative environment.