Responsible for educating the individual Care Management regional departments on the regulatory requirements from all regulatory organizations (CMS, NCQA and contracted Health Plans) and for assisting the regions in maintaining regulatory compliance of Care Management processes. Acts as a resource in the areas of referral processing, denial letter processing and clinical decision-making.
Conducts regional-based training to educate Care Management staff on health plan regulatory procedures and processes.
Acts as a central resource with regards to regulatory requirements from participating regulatory agencies, health plan clinical review criteria and HMO benefits.
Contributes pertinent utilization-related materials to the departmental intranet site.
Assists in preparing the department for annual health plan audits.
Conducts review of procedures related to referral processing including oversight of denial letter processing.
Performs reviews as needed on other related Care Management processes including retrospective and prospective review of referrals and appeals review.
Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of appropriate reports (Health Plan Eligibility and Benefits, Division of Responsibility (DOR)).
Communicates authorization/denial for services to appropriate parties including patient (or agent), attending/referring physician, facility administration and HCP Claims Department as necessary.
Participates as requested in assigned Care Management Committee meetings. Addresses pertinent regulatory information to all members of the health team when appropriate.
Contributes to current Care Management programs within the policies and procedures set by the Care Management Department.
Contributes to team decisions in the development and enhancements to the Electronic Referral Management system.
Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients and families.
Initiates or oversees data entry into IS systems within the parameters of Care Management policies and procedures. Maintains accurate and complete documentation of services requested including CPT code, ICD-9, referral type, date, etc.
Uses, protects, and discloses HCP patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
1 or 2 years of post-high school education or a degree from a two-year college.
Graduation from an accredited school of Nursing.
Current California LVN license.
Over 1 year and up to and including 3 years of clinical experience.
At least 1 year of recent clinical experience
3 to 5 years of recent clinical nursing experience.
Previous care management, utilization review or discharge planning experience.
Managed care experience.
KNOWLEDGE, SKILLS, AND ABILITIES
Knowledge of current standards of patient care.
Thorough understanding of LVN scope of practice.
Manual dexterity to use/handle equipment and instruments.
Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.
Ability to make sound, independent judgments and act professionally under pressure