Concurrent Review Nurse

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

This position performs and manages all aspects of case management to include utilization management. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high quality care and cost-efficient outcomes through the process of case management. This position requires excellent communication and diplomacy skills in managing complex working relationships.

Reviews preservice requests routine and urgent and encourage high quality care and to achieve cost effective outcomes. Will utilize NCDs, LCDs and MCG to assist in determining coverage of the request. Performs concurrent review on all Members that are at an inpatient or observation level of care. Will communicate with the facility case manager to assist in discharge planning to appropriate level of care. Will ensure all discharge needs are met. Interfaces with physician and clinical staff to ensure continuity of care. Works in coordination with case management projects. Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG , NCD , LCD and community standards of practice and regulatory developments, and new and experimental procedures). Adheres to company and department policies and procedures. Communicates with customers, both internal and external, regarding status of referral/referral process. Resources for physician, vendors or contracted providers, regarding benefits. Multiple projects under the direction of the utilization department Supervisor. Transferring patients from non-contracted to contracted vendors with contract changes. Initiation of case management for complex, high utilization members to include identification, assessment of needs, planning and coordination of care, and monitoring of outcomes. Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. Performs other duties as assigned