Job Overview

Company: Blue Cross Blue Shield of Michigan

Contact: Not Available

Location: US-MI-Ann Arbor

Base Pay: N/A

Employee Type: Full-Time

Industry: Healthcare - Health Services
Managed Care

Manages Others: Not Specified

Job Type: Nurse

Required Education: Not Specified

Required Experience: Not Specified

Required Travel: Up to 25%

Relocation Covered: Not Specified

 

Job Description

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****BCN - ANN ARBOR location*****
 
Perform review of inpatient, outpatient, and ancillary services as required either on site or telephonically.  Perform review on admissions to ensure medical necessity, appropriate length of stay, appropriate intensity of service and level of care, and appropriate utilization of ancillary services.  Establish care plans and coordinate care through the health care continuum.  Demonstrate consistent reviews utilizing national standardized criteria and sound nursing judgment. To collaborate with providers and members to assess, plan, implement, coordinate, monitor and evaluate options and services to meet individuals health needs through available resources to promote quality cost effective outcomes.
 
Review requests for authorization of elective, direct, urgent, and emergent inpatient services within department timeframes. Review requests for authorization of home care, home infusion and DME services. Contacts appropriate medical and support personnel. Identify alternate methods of treatment, levels of services, and/or length of stay, and make recommendations.  Authorize medically appropriate services and length of stay.  Document relevant case data.  Use approved clinical protocols, criteria and guidelines in decision-making. Identify members, who may benefit from internal programs such as disease state management, case management, etc. Establish a preliminary discharge plan for all admissions at the time of admission and modify this plan, as appropriate, prior to discharge to meet the member's needs/goals.  Coordinate and communicate discharge-planning needs with appropriate team members, medical personnel, members and their caregivers. Conduct after care follow up of members upon discharge to provide education and coordinate care as well as to assess the member's current health status. Analyze patterns of care that may be associated with progression to severe disease.  Conduct pre and post op assessments of specific members.  Identify contractual services and organize delivery through appropriate channels. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and Mental Health and Substance Abuse care coordination. Actively promote communication between member, family, providers and all parties involved. Identify and document quality of care issues, and resolve, or route to Quality Management for handling. Follow out-of-area/out-of-network inpatient services and make recommendations on patient transfer to in-network facility and/or alternative plan of care. Develop and deliver education for provider community regarding policies, procedures, benefits, co-pays, etc. and medical management programs related to all product lines. Promote and engage in positive and constructive daily teamwork, participate in after hours call schedule, and perform other duties as needed.

 

Job Requirements

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• Registered Nurse with current, valid Michigan license required.
• Bachelor's Degree in nursing, allied health, business or related field preferred.
• Certification in case management preferred.
• Three (3) years of acute patient care with broad clinical background required.
• Two (2) years utilization review, discharge planning, case management, home care preferred in addition to the above.
• One (1) year experience in a managed care environment preferred.
• Managed care philosophy, policies, and procedures
• Application of clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management.
• Medical Management processes across the continuum of care.
• Current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing
• Current medical practices using alternative care settings and levels of service- home care, skilled nursing facilities, sub-acute, hospice and home infusion.
• Cost containment strategies regardless of limitations of policy/benefits available to the member
• Local/national community resources
• Medical terminology and ICD-9 and CPT coding
• State and Federal HMO regulations preferred
• Excellent written and verbal communication skills required.
• Excellent documentation skills required.
• Excellent customer service and interpersonal skills including the ability to interact with internal and external customers and all levels of the organization required.
• Strong problem-solving, analytical and decision making skills required.
• Strong organizational, planning and implementation skills with the ability to handle multiple project and timelines required.
• Creative and resourceful with good negotiating skills required.
• PC literate.
• Ability to work well with minimal supervision
• Prolonged wearing of telephone headset to answer calls
• Prolonged periods of focusing on computer screens to enter data
• Prolonged periods of keying data
• Prolonged periods of sedentary activity
• Daily Travel to assigned on site facility where applicable
• Cubicle
• Moderate noise level
• Valid current Michigan driver's license and personal means of reliable transportation for nurses on site.
• Proof of auto liability coverage for nurses on site.