Functions as the liaison for hospital staff, PCP, other healthcare team members and company staff telephonically. Educates network providers on Plan benefits and network services. Responsible for maintaining current knowledge of the developments in medical technology, and legislation pertinent to managed care settings, patient rights, safety regulations and contractual and organizational specific requirements.

Key Functions/Responsibilities:

• Determines the medical necessity of the acute inpatient, skilled nursing, and acute rehabilitation stays according to established criteria and telephonically coordinates transfers to participating facilities according to certain factors, such as patient condition, and network resources.
• Monitors patients’ lengths of stay and documents pertinent clinical information for cases referred to Care Management or Plan Medical Director, within required timeframe guidelines.
• Identifies and manages those members who do not meet Hospital Level of Care (HLOC) per company policy, while notifying appropriate providers of the specific cases and maintaining documentation.
• Conversion of Hospital Level of Care admissions to Administratively Necessary Days or Observation status.
• Anticipates member’s post discharge needs and is proactive in conducting preadmission reviews for admission to skilled nursing facilities and acute rehabilitation facilities. (Note: New Hampshire processes will need to be followed regarding lower levels of care.)
• Assists providers in effectively providing inpatient discharge planning.
• Participates in or leads clinical quality projects along with the Division of Medical Assistance and New Hampshire quality goals.
• Provides mentoring and guidance to Inpatient UM Specialists to ensure timely discharges, RC2 Upgrades and High Cost Referrals.
• Refers to CM any member that meets the established guidelines.

Qualifications:

Education:

• Bachelors Degree in Nursing or Nursing School Degree with equivalent relevant work experience.
• CCM certification preferred.

Experience:

• 3 years related experience in an acute care or health insurance environment.
• 2 years experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.

Preferred/Desirable:

• Experience in acute care and/or rehab nursing.
• Experience with Medicaid recipients and community services.
• Experience with FACETS, CCMS, InterQual™ or other healthcare database.

Certification or Conditions of Employment:

• Current state licensure as a Registered Nurse.

• Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.