Case Manager Licensed Practical Nurse

Job Summary

Job Duties

• Performs onsite assessment and telephonic review of admitted Members to determine appropriate management through facts documented in the medical record or recognized from contact with the Member or facility staff.
• Actively involve with facility staff to insure adequate, appropriate and timely discharge planning.
• Works with designated transplant vendor to actively manage Members who are identified as requiring transplant.
• Coordinates approval for services within the transplant vendors and the Health Plan network of facilities and completes documentation in the Medical Management computer systems to assure appropriate application of benefits.
• Performs prior authorization for items on the prior authorization list; performs precertification through on-site, electronic or telephonic concurrent assessment or retrospective review of Members admitted to acute and sub-acute inpatient facilities, as well as members in an at home setting to assure appropriate utilization through facts documented in the medical record or recognized from contact with the Member, Member's family, or facility staff.
• Actively engages with facility staff to assure adequate, appropriate and timely discharge planning.
• Interacts with Members, Members' families and Authorized Representatives as needed to explain benefits, assist with discharge planning, notify of denial of coverage with explanation of Peer to Peer and Appeal Rights.
• Complies with all regulatory guidelines related to utilization management processes and assures that all regulatory time frames for decision-making are met.
• Provides benefit focused case management, coordinating care in accordance with the member's benefit document to members authorized for services outside the health plan network.
• Provides assistance to eligible members seeking continuity and coordination of care when all conditions of policy are met for Provider or Practitioner terminations for reasons other than cause and for new members currently undergoing treatment by a Practitioner or Provider who is not participating with the Health Plan.
• Provides On-Call coverage, on a rotating basis as assigned, for services during non-business hours.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Education

Experience

Certification(s) and License(s)