Medical Case Manager (RN)

To Apply for this Job Click Here

POSITION:            Medical Case Manager (RN license required)
SCHEDULE:         Full-Time, Mon-Friday 8AM- 4:30PM
FACILITY:             Wexford Health Regional Office
LOCATION:          10 Park Street, Concord, NH 03301 (lot parking)
 
Wexford Health Sources, Inc. is one of the nation’s largest correctional health care providers.  Over the past 30 years, our team of dedicated clinical professionals has helped millions of justice-involved patients receive life-changing medical and mental health services.

BENEFITS

• Annual review with performance increase
• Generous paid-time off program that combines vacation and sick leave
• Paid holidays
• Comprehensive health insurance through Blue Cross Blue Shield
• Dental and Vision insurance
• 401(k) retirement saving plans
• Company-paid short-term disability
• Healthcare and dependent care spending account

POSITION SUMMARY
The Medical Case Manager assists with managing medically complex cases, those hospitalized, medical parole cases, and resolving resident medical concerns. He/she ensures cost effective outcomes while maintaining a focus on quality care for inpatient and/or outpatient services. He/she monitors on-going medical needs and services by engaging in the following: evaluating medical necessity, appropriateness and efficient use of Health Care Services for inpatient hospitalizations and/or outpatient procedures, working closely with physicians, hospital utilization management and correctional facilities to provide quality, cost-effective care at the level most appropriate to the inmate-patient; and providing reports and recommendations to medical and facility staff for improved utilization of resources.

DUTIES/RESPONSIBILITIES
INPATIENT SERVICES:
1. Works with patients and providers for the patients' best interests by helping to ensure appropriate care and maximizing clients' medical benefits;
2. Reviews clinical information provided by the Hospital Utilization Management Departments for appropriateness of care, medical necessity and appropriate level of care;
3. Utilizes InterQual Criteria and/or Milliman Admission Criteria to guide admission necessity and continued stay review.
4. Maintains a paper case of clinical information; and access computer system to obtain reference numbers for hospital billing and claims payments.
5. Reviews clinical information with appropriate Physician and other clinical staff to facilitate discharges back to the infirmary.
6. Works with operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
7. Issues notices of non-coverage in conjunction with Chief Medical Officer.
8. Prepares appeals of non-covered services for Chief Medical Officer review and updates computer system as appropriate.
9. Maintains monthly tracking statistics for communication log compliance and for repeat admits.
10. Prepares daily summary report and distributes to appropriate personnel
OUTPATIENT SERVICES:
11. Reviews requests for outpatient/onsite services and obtains history and clinical rationale. Reviews and maintains all contractual turnaround times.
12. Obtains all necessary clinical information, history, criteria, and present findings to Chief Medical Officer for inpatient and/or outpatient review.
13. Enters all information, from the referral review in accordance with contractual turnaround times
14. Reviews launch reports to monitor appropriateness and accuracy of the entry process.
15. Verifies response back to schedulers with results of referral review within contractual timeframe
16. Works with schedulers to ensure that appointments are obtained and that patients are seen within specified dates of approval
17. Provides site and providers with authorization number/letter according to policy.
18. Pre-certifies specific surgical cases when applicable as outlined in the policy and procedures.
19. Reviews history of all consults and raises question of a possible quality of care issue or risk management issue to Chief Medical Officer.
20. Works with operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
21. Assists Team with contractual issues and updates.

JOB REQUIREMENTS
TRAVEL: May be required to travel to any NHDOC facility.
LICENSING: Current New Hampshire Registered Nurse license
CERTIFICATION: Current CPR certification preferred
EXPERIENCE: 

EDUCATION: Graduate from an accredited School of Nursing

.

22689

,
,
,
,

,

To Apply for this Job Click Here