On-Call position to cover staff on leave.
GENERAL SUMMARY
Reviews all inpatient admissions to assure appropriate level of care. Coordinates with physicians, staff, and facilities regarding patient care. In conjunction with and under the supervision of physicians, evaluates care plans and discharge plans, monitors all clinical activities, identifies alternative levels of care when requested care is not covered, identifies cost-effective protocols, and develops guidelines for coverage of benefits.
ESSENTIAL RESPONSIBILITIES
- Monitors all inpatient care provided to members. In conjunction with and under the supervision of physicians, evaluates and provides feedback to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.
- Coordinates, directs, and performs concurrent and retrospective reviews; monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Coordinates an interdisciplinary approach to support continuity of care. Identifies covered services, including utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for outside services for patients/families.
- Consults with physicians, health care providers, and outside agencies regarding continued care/treatment or hospitalization.
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
- Interprets health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Actively participates in the discussion and notification processes that result from the medical record reviews with the facilities. Prepares notification letters of denied and negotiated days within the established time frames.
- Assists in the identification and reporting of potential quality improvement issues.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state RN license preferred.
- Significant (usually 3+ years) clinical experience
- Utilization Management experience required
- Computer Skills - Microsoft Suite
- Medical record review experience
OR
- Licensed Practical Nurse with active state LPN license.
- Minimum 3 years clinical experience required
- Minimum 5 years Utilization Management experience required
- Computer Skills- Microsoft Suite
- Medical record review experience
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Metairie, LA, US
Organization: 14000 - CHC of Louisiana
Schedule: Part-time
Job Posting: 2013-01-11 00:00:00.0
Job ID: 1310125