Case Management Nurse
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Wichita, KS 67202
Case Management Nurse
Location: Wichita KS
With the support of the department manager, carries primary and independent responsibility for the day-to-day operations of reviewing, processing, and communicating with members and providers involved in case management activities, which may include determining appropriateness and cost effectiveness of care in light of quality of care objectives. This position serves as primary negotiator with medical providers/vendors regarding reimbursement and provider write off of services involved in specific managed care cases. Also carries primary responsibility for pre- and post- case management claim payment. Provide backup support for Precert activities. Responsible for performing all activities within State, URAC, HIPAA, DOL, and MTM goals or guidelines.
Specific Duties of Job
- Responsible for timely resolution of case management referrals.
- Assume a leadership role in determining the financial direction of patient care. This diverse activity requires the case manager to facilitate the development of a treatment plan that will meet the patient’s needs. On a limited basis, appropriately negotiates reimbursement with providers that will be acceptable to all parties (patient, family, providers, and Blue Cross and Blue Shield of Kansas) at the most cost effective prices that will meet the patient’s short and long range goals. The case manager must determine if the sum of the cost of services will result in high quality care that is equal to or better than the alternatives. All cases require care coordination with multiple providers to include transitions of care as the patient moves through the health care continuum. Monitors ongoing services and evaluates plan effectiveness to facilitate changes, if appropriate.
- The case manager must be knowledgeable of current URAC Case Management requirements and perform job functions to meet these requirements.
- The case manager must be knowledgeable about the cost/price and reimbursement structures in health care regarding but not limited to: private duty nursing, antibiotic intravenous (IV) and total parenteral therapy, home ventilation care, high risk infant and newborn care, rehabilitation, and pre- and post-transplant care, to name a few.
- Responsible for providing quality case management services in a manner compliant with department case management quality indicators.
- Obtains, records, and coordinates all case management inquiries and relays information to departments including Medical Director, Blue Cross and Blue Shield of Kansas Customer Service representatives, claims staff, Marketing, Institutional and Professional Relations, Behavioral Health Vendor, and Legal Counsel when necessary.
- Has freedom to obtain and conduct review of medical information without direct supervision. Must determine through independent medical knowledge which cases require medical consultant expertise. All such determinations must be made under limited and extreme time restraints.
- Participate in telephone and/or onsite case management decision teams, which may involve interaction with one or all of the following: patient, referring physician, treating physician, facility staff and caregivers, financial officers and/or representatives.
- Responsible for analyzing atypical or complicated cases and case management claims until resolved to include preparing and presenting case scenarios to the Corporate Medical Director with appropriate medical, financial or cost/benefit information for review and input.
- Responsible for identifying potential quality of care issues and making appropriate referrals.
- Prepares detailed reports on cases as required, which may include: interacting directly or indirectly with employer decision makers regarding care and cost benefit with our services.
Assists with the gathering of quality assurance/utilization management data, problem identification and analysis of data. This includes development of criteria and guidelines.
- Maintains appropriate caseload, follows case management process to include appropriate documentation and follow-up.
Registered Nurse with minimum of three to five years clinical nursing experience; acute medical/surgical experience preferred
Bachelor of science in nursing (BSN) preferred. Current unrestricted Kansas RN license required.
- Case Management experience, which includes negotiating reimbursement levels preferred.
Experience with InterQual Medical/UM screening criteria and multiple IT/computer systems preferred.
- Eligibility for CCM certification preferred.
CCM certification required within two years of employment.