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- Farmington, CT
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Registered Nurse - UM
Emblem Healthcare-Home Health & Hospice • Farmington, CT
Posted 11 days ago
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ConnectiCare is a leading health plan in the state of Connecticut. A local company for more than 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. By striving to make it easy for members to get the care they need, ConnectiCare leads the individual market in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance. ConnectiCare is a subsidiary of EmblemHealth.
We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.
Summary of Job: Performs clinical reviews within the Medical Management Operations Concurrent Review utilization management department, ensuring accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.
- Under the direction of the Supervisor, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
- Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting. Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
- Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
- Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
- Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards. Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
- Prepare and present clinical case summaries in routine inpatient rounds.
- Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
- Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
- Actively participate on assigned committees.
- Perform other related projects and duties as assigned
- For RNs: Associate’s degree or Bachelor’s degree in Nursing with 3-5 years of clinical nursing experience. Valid RN License in the State of CT without restriction. May require a CME accreditation in specific specialties
- Prior case and/or utilization management/care coordination and managed care experience preferred
- Certification in utilization or care management preferred
- Strong oral and written communication, organizational, and interpersonal skills required. Trained in the use of Motivational Interviewing techniques a plus
- Experience working in physician practice and/or with electronic medical records preferred
- Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.)
- Previous system user experience in a highly automated environment and strong personal computer literacy on Windows products required
- Bilingual in English/Spanish or English/Polish a plus
- Strong cross-group collaboration, teamwork, problem solving, and decision making skills
- Presentation, analytical and negotiation skills
- Manage a flexible work schedule to meet member and/or caregiver and departmental scheduling needs
Essential Job Requirement:
- Primarily sedentary
- Must be able to use standard office equipment