RN Complex Case Manager Medical Management HFHP FT PC # 18960 - Health First Health Plans, Inc - Rockledge, FL

RN Complex Case Manager Medical Management HFHP FT PC # 18960 - Health First Health Plans, Inc - Rockledge, FL -

The HFHP Case supervisor is accountable and accountable for offering High quality / No Hurt, Buyer Expertise, and Stewardship by finishing a radical Evaluation, Plan of Care improvement, implementing, monitoring and modifying Plan of Care as wanted and figuring out medical and monetary outcomes. The Case Manager promotes and evaluates the efficient utilization of assets utilizing present medical information, consciousness of group assets/providers and functioning as a member advocate to make sure optimum case outcomes.

Main Accountabilities

Performs critiques to guarantee members are receiving care within the applicable setting on the applicable degree.

Collaborates with members of the healthcare workforce to facilitate continuity of care, care plans, discharge planning and/or transition of care.

Collaborates with Medical Director relating to problems with medical necessity, profit protection and availability of providers.

Updates authorizations with accuracy and completeness to help correct declare funds and collaborates with Utilization Management staff to guarantee applicable care.

Determine members applicable for different Health First Health Plans program referrals in addition to referrals to group assets/providers.

Different Health First Health Plan packages to incorporate Inspiris/Care Degree Management, Circles of Care and Illness Management packages.

Different Health First Health Plan packages to incorporate Case Management, Care Degree Management, Circles of Care and Health Dialog.

Makes use of Health First Health Plan assets in a price efficient method.

Doc member value financial savings based mostly on applicable utilization of providers and proof based mostly care.

Determine and doc various value saving choices for members.

Qualifications

Present FL RN license required.

Bachelor’s Diploma in Nursing most popular plus 5 years medical expertise.

Favor at the least two years earlier expertise to incorporate Utilization Management, Managed Care, and/or Staff Compensation/Incapacity Medical Management.

CCM most popular; if not licensed, should turn out to be a Licensed Case Manager inside two years of becoming a member of the division.

Information of CPT codes, HEDIS, HIPAA, ICD-9 codes, Medicare Tips, and NCQA.

Information of Coordination of Advantages the place relevant (i.e., Staff Compensation, Auto Insurance coverage, Brief and Lengthy Time period Incapacity).

Information of Billing and Claims processing.

Information of applicable referrals to Ethics Committee, Company Compliance, Fraud and Abuse or Authorized Providers when applicable.

Information of Reimbursement throughout the continuum of healthcare to suggest various remedy choices.

Information of other remedies choices, various funding packages and group providers and assets.

An individual of excellent ethical character with not one of the following: employment discharge or reprimands on account of dishonesty, felony convictions (convictions for sexual assault, abuses, molestation, indecent solicitation, obscenity, or different acts of ethical turpitude), arrested/accused/convicted of regulation/ordinance violation, grants of immunity in a grand jury continuing and used the CCM designation with out being licensed.

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