Nurse Consultant II
Company: GEHA, Inc.
Location: Lees Summit
Posted on: January 11, 2021
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Job Description:
Summary Performs essential functions of care management for
identified and assigned member population according to HIPAA
guidelines. Manages a specified caseload; coordinating health care
benefits, providing education and facilitating member access to
care in a timely and cost-effective manner. Collaborates and
communicates with member, family, and health team to promote
wellness and member autonomy, while ensuring access to appropriate
services across the healthcare continuum and maximizing member
benefits. Serves as clinical advocate for members and liaison with
other departments and external health care team. Uses claims
processing and care management software to look up member
information, document contacts, and track member progress.Duties --
Evaluates information regarding prospective care management members
referred by providers utilization review vendors, members, Claims
and Call Center staff or data sources to determine whether medical
care management intervention is necessary to meet the member's
needs.-- Manages a participant caseload including communication
with participants, providers and family or authorized
representatives. Reviews member claims histories and identifies
intervention opportunities. Contacts and interviews members to
conduct a baseline assessment, assess self-care ability, assess
knowledge and adherence deficits.-- Collaborates with primary care
physician and other treating professionals as appropriate.
Authorizes initiation of care management services and specialized
program services for members and specific populations, and develops
interventions designed to meet member or population desired
outcomes. Educates members about accessing services, in-network
use, national guidelines for care, and self-management skills and
strategies.-- Employs engagement techniques to build relationships
with members and their authorized representatives.-- Encourages
participants to participate in their health care decisions and
assists member with researching treatment options in order to
communicate effectively with providers and to make informed
decisions.-- Provides direction and assistance to Cost Utilization
Specialists regarding benefit approvals and denials. Notifies Cost
Utilization Specialists of participant's needs including the need
for special educational mailings, reminder calls, satisfaction
surveys, incentives or any additional service needs according to
specific program guidelines.-- Collaborates with the GEHA Medical
Director regarding complex benefit decisions and obtains medical
approval of denials per department guidelines. Processes benefit
determinations according to company policies.-- Facilitates
appropriate use of resources and coordinates necessary services to
improve health status and impact the cost of care. Identifies
member needs and refers to appropriate internal and external
programs, as appropriate. Redirects members and providers to
in-network facilities when available. Negotiates rates for those
services provided out of the network, as well as high dollar
services provided in network, when appropriate.-- Researches new
medical technologies and standards: reviews information from the
peer reviewed literature and approved websites. Encourages member
and family empowerment through education and use of reliable
resources.-- Monitors and evaluates member progress: evaluates
member-response to interventions and refines action plan to produce
desired outcomes. Identifies complex care management issues and
discusses possible solutions with management. Assesses
program/project effectiveness.-- Uses claims and care management
software to document interactions and interventions with members,
vendors, and providers. Maintains case information in the member's
clinical records to promote care coordination and accurate and
timely claims payment. Identifies cost-savings activities and
documents in care management software, including rationale for
care.-- Works collaboratively with peers and management to identify
department opportunities for improvement using member feedback,
clinical or program experience, and available data. Actively
supports initiatives specific to improvement of department clinical
and financial outcomes.-- Provides ongoing direction and support to
internal customers regarding Care Management programs, processes,
and benefit coverage.-- Takes accountability for obtaining and
maintaining nursing licensure in all states as required. Takes
accountability for the identification of personal educational needs
and works with management to develop a plan for obtaining the
necessary training.Job Requirements:Education Requirements Requires
a Bachelor's degree, current RN license in good standing in state
of residence and must be eligible for licensure in all 50 US
states. Additional years of qualifying work experience may be
considered in lieu of Bachelor's degree.Experience Requirements--
Requires two years of recent RN care management experience in a
hospital or managed care setting, such as a health insurance
environment.-- Requires at least three years of nursing experience
in a clinical setting.-- Requires current knowledge of clinical
standards of care and disease processes.-- Requires critical
thinking skills, effective verbal and written communications skills
to consult with physicians and providers, and demonstrated ability
to negotiate costs.-- Requires basic computer skills and knowledge
of medical information systems. Required to coordinate the demands
of cost control and service responsiveness for members in
catastrophic medical situations.-- Incumbent is required to
disclose all adverse actions imposed by any State Board of
Nursing.GEHA is an Equal Opportunity Employer. GEHA will not
discriminate against employees or applicants because they have
inquired about, discussed, or disclosed their compensation or the
compensation of another employee or applicant. Our company's
corporate headquarters is located in Lee's Summit near Douglas Rd
and I-470 with a total of five locations in the Kansas City
metropolitan area.
Keywords: GEHA, Inc., Lee's Summit , Nurse Consultant II, Professions , Lees Summit, Missouri
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