RN Care Champion - MyNavigator- Full Time - Days
The Care Champion, EHP Service Team (Utilization Management RN) will be a key member in a cross functional team of caregivers and customer service representatives who provide exceptional customer service and complex utilization care management services to members needing assistance with their benefit plan, navigating the healthcare system, understanding or managing their condition, or need assistance coordinating care and services.
Review of prior authorization requests for medical necessity based on established medical policy, InterQual®, or other evidence based criteria
Evaluate medical necessity and utilization management of surgical procedures, inpatient admission based on InterQual® or other evidence based criteria
Facilitate transitions of care across the continuum of settings
Monitor potential complex cases and collaborate with other team members for further assessment and care coordination
Authorize specific inpatient, outpatient, professional and ancillary services and out-of-plan services to ensure appropriate care and proper use of applicable provider panel and ancillary services
Confer with physician offices, ancillary providers, Case Managers and Plan Medical Director/Associate Medical Directors on pertinent case questions or situations, as appropriate
Assists in development and implementation of Utilization/Care Management outcome metrics and utilizes outcome metrics to identify quality improvement opportunities
8. Provide best in class customer service to members and providers
Perform other duties, as assigned
Education: Current Ohio and Michigan Registered Nurse License required (Michigan registered nurse’s license must be obtained within three months of employment)
- Excellent critical thinking skills.
- Strong and deomstrated customer service skills.
- Possess excellent time management skills.
- Excellent interpersonal, communication (oral, telephonic, and written) and organizational skills required. Ability to plan, coordinate and organize multiple priorities.
- Knowledge of InterQual® or similar criteria, ICD-10, CPT, and DRG coding.
- Demonstrated working knowledge in Word, Excel, Outlook, internet, and electronic medical record proficiency.
- Ability to be compassionate, member centric while ensuring coordination and support of medically necessary, evidenced based, high quality care delivered in the appropriate setting.
Years of Experience: Minimum 2-3 years recent clinical experience and 2 years utilization management experience in the insurance industry.
Education: Current Ohio and Michigan nursing license (Michigan registered nurse’s license must be obtained within three months of employment) .
- Experience in a provider setting with demonstrated problem-solving and organizational skills, excellent oral and written communication skills and effective interpersonal skills strongly preferred.
- Recent experience in public health, managed care, or quality improvement environment required.
- Ability to develop and present data in meaningful ways to clinical and financial staff.
- Strong knowledge of governmental regulations related to member/provider appeals and grievances.
- Demonstrated ability to handle confidential information in a professional and appropriate manner required.
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact firstname.lastname@example.org
Equal Opportunity Employer/Drug-Free Workplace
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