- Utilizes clinical experience and appropriate clinical criteria and guidelines, along with Plan provisions, in monitoring, evaluating and coordinating both inpatient and outpatient medical care to promote quality outcomes at reasonable costs.
- Performs prospective and concurrent utilization reviews to determine medical necessity for inpatient admission, inpatient continued stay and selected outpatient services to ensure medically appropriate, high quality and cost effective care and for most efficient utilization of third-party services.
- Assists members (associates, retirees and dependents) in navigating the healthcare landscape and optimizing benefit plan utilization by identifying opportunities to promote quality healthcare.
- Monitors potential high-cost claims for early intervention with case management and retrospectively reviews to assure appropriate and cost effectiveness.
- Communicates regularly with members, physicians, physician office staff, pharmacists and hospital utilization personnel.
- Conducts and coordinates case management activities for non-occupational Short-Term Disability, return-to-work and Family Medical Leave Act cases.
- Keeps management and internal physician consultants informed on an ongoing basis of the status of all large case management cases. Collaborates with management and/or the internal physician consultants on a case-by-case basis.
- Acts as a source of medical information for Benefits Department.
- Keeps up-to-date on current medical trends by regularly reviewing journals and professional publications and attending seminars.
- Documents individual cases for the purposes of cost savings and efficiency analyses and legal record.
- Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality and protection of personal information, including, but not limited to, personal health information and personally identifiable information.
- Provides support as needed for the Company's occupational nurse and wellness programs.
- Performs other duties as assigned by management.
- Demonstrated working knowledge of utilization management principles, including effective use of physician consultants, structure and operation of preadmission review, concurrent review, discharge planning, second opinion, catastrophic case management programs, ACD telephone systems and data collection, analysis and reporting.
- Proven familiarity with the major criteria sets and length of stay guidelines currently used by most systems.
- Demonstrated working knowledge of International Classification of Diseases - 10 codes (ICD-10).
- Proven familiarity with ICD10-CM and CPT-4 coding and DRG-based systems.
- Demonstrated strong knowledge of medical technology, healthcare resources and contemporary trends in the healthcare delivery system.
- Proven experience handling multiple duties and completing assigned tasks accurately and on a timely basis. Must cite examples of proven ability to work independently to schedule and initiate reviews and work with patients, providers and claim processors.
- Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate with all levels of administration, healthcare providers and members in a clear, focused and concise manner. Expected to provide examples of written work such as correspondence, reports, etc.
- Demonstrated high level of customer focus and ability to maintain a positive attitude at all times.
- Demonstrated complete discretion in handling confidential and sensitive materials.
- Works in an office setting and remains continuously in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.
- Frequently moves around the office to access file cabinets, office machinery, etc. While accessing file cabinets, frequently uses upper extremities to reach by extending hands and/or arms in any direction.
- Bachelor's degree in Nursing.
- Proficient in word processing and spreadsheet applications.
- Case/claim management system experience a plus.
- Registered nurse in the state of Ohio.
- Extended hours required during peak workloads or special projects.
-
Intensive Care Nurse
3 weeks ago
Prolink Cincinnati, United StatesProlink is hiring local or travel RN Burns Surgical Care Unit / ENT ICU for one of the top hospital networks in Cincinnati, Ohio. · Contract Details: · Start date: 5/28/2024 ort 6/10/2024 · Length: 13 weeks · Shift: AM or PM · Hours: 36 hours · Every Other Weekend Required · Eve ...
-
Intensive Care Nurse
2 weeks ago
Prolink Cincinnati, United StatesProlink is hiring local or travel Neuro Surgical ICU/PCU RNs for one of the top hospital networks in Cincinnati, Ohio. · Contract Details: · Start date: 6/10/2024 · Length: 13 weeks · Shift: Flex or PM · Hours: 36 hours · Every Other Weekend Required · Every Other Holiday Require ...
-
Medical Care Nurse
2 weeks ago
Alternate Solutions Health Network LLC Hamilton, OH, United StatesAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health Case Management for a nursing job in Hamilton, Ohio. · Start Date: ASAP · Employment Type: Staff · The Ohio State University Wexner Medical Center Home Care · Our culture and people are what ...
-
Medical Care Nurse
3 weeks ago
Alternate Solutions Health Network LLC Cincinnati, OH, United States Part timeAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health Case Management for a nursing job in Cincinnati, Ohio. · Start Date: ASAP · Employment Type: Staff · The Christ Hospital Home Health Care · Our culture and people are what set us apart from ...
-
Cardiovascular Intensive Care Nurse
2 weeks ago
Prolink Cincinnati, United StatesProlink is hiring local or travel CVICU RNs for one of the top hospital networks in Cincinnati, Ohio. · Contract Details: · Start date: 6/10/2024 · Length: 13 weeks · Shift: PM · Hours: 36 hours · Every Other Weekend Required · Every Other Holiday Required · Requested time off: ...
-
patient care tech or student nurse
4 weeks ago
Bon Secours Mercy Health Cincinnati, OH , USA, United StatesAt Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. · **Job Summary:** · A Patient Care Technician (PCT) provide ...
-
registered nurse acute care rn
3 weeks ago
TriHealth, Inc. Cincinnati, OH , USA, United States Full timeJob Overview: · This position applies the nursing process in providing direct and indirect holistic care to patients and their families. The position also collaborates, in a collegial manner, with physicians and other health care team members in meeting the patient's needs. This ...
-
Travel Critical Care Registered Nurse
3 weeks ago
Insight Global Cincinnati, United StatesJob Description · A Hospital in the Cincinnati area is expanding with two new inpatient units and looking to hire nurses who will be responsible for delivering high-quality care to patients based on assessed needs, established stands of care and according to policy and procedures ...
-
Travel registered nurse care unit
1 week ago
ARMStaffing Cincinnati, OH, United StatesARMStaffing is looking for RN - Dialysis in Cincinnati, Ohio · Shift: 12 Hour Day, 07:00:00-19:00:00, 12.Unit Details: At ARMStaffing we take care of our nurses Health & Retirement Benefits · Day-1 access to extensive benefits including Medical, Vision, Dental, Life and more... · ...
-
Heart2Heart HHC Inc. Cincinnati, United States Full timeBenefits/PerksFlexible Scheduling · Competitive Compensation · Career Advancement · Job Summary · We are seeking experienced home health care professionals/Certified Nursing Assistants (CNA) to join our team. In this position, you will assist patients with their daily living nee ...
-
Medical Care Nurse
2 weeks ago
Alternate Solutions Health Network LLC Hamilton, OH, United StatesAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health for a nursing job in Hamilton, Ohio. · Specialty: Home Health · Start Date: ASAP · Employment Type: Staff · The Ohio State University Wexner Medical Center Home Care · Our culture and peopl ...
-
Medical Care Nurse
3 weeks ago
Alternate Solutions Health Network LLC Cincinnati, OH, United States Part timeAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health Case Management for a nursing job in Cincinnati, Ohio. · Start Date: ASAP · Employment Type: Staff · The Christ Hospital Home Health Care · Our culture and people are what set us apart from ...
-
Medical Care Nurse
2 weeks ago
Alternate Solutions Health Network LLC Hamilton, OH, United StatesAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health for a nursing job in Hamilton, Ohio. · Specialty: Home Health · Start Date: ASAP · Employment Type: Staff · The Ohio State University Wexner Medical Center Home Care · Our culture and peopl ...
-
University of Cincinnati Cincinnati, United StatesCurrent UC employees must apply internally via SuccessFactors > · You are invited to submit an application to be considered for a position with more than one opening. The number of positions varies depending on the needs of the department. · Founded in 1819, the University of C ...
-
Licensed Practical Nurse-staff-acute Care
3 weeks ago
TriHealth, Inc. Cincinnati, United States Part timeJob Overview: · This position contributes to the nursing assessment by collecting, reporting, and documenting objective and subjective data. This position also participates in the development of the Nursing component of the plan of care at the direction of an RN, physician, denti ...
-
Medical Care Nurse
2 weeks ago
Alternate Solutions Health Network LLC Hamilton, OH, United StatesAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health for a nursing job in Hamilton, Ohio. · Specialty: Home Health · Start Date: ASAP · Shift: evenings · Employment Type: Staff · The Ohio State University Wexner Medical Center Home Care · Ou ...
-
Medical Care Nurse
2 weeks ago
Alternate Solutions Health Network LLC Hamilton, OH, United StatesAlternate Solutions Health Network LLC is seeking a Registered Nurse (RN) Home Health for a nursing job in Hamilton, Ohio. · Specialty: Home Health · Start Date: ASAP · Employment Type: Staff · The Ohio State University Wexner Medical Center Home Care · Our culture and peopl ...
-
Heart2Heart HHC Inc. Cincinnati, United StatesJob Description · Job DescriptionBenefits/PerksFlexible Scheduling · Competitive Compensation · Career Advancement · Job SummaryWe are seeking experienced home health care professionals/Certified Nursing Assistants (CNA) to join our team. In this position, you will assist patien ...
-
Heart2Heart HHC Inc. Cincinnati, United StatesJob Description · Job DescriptionBenefits/PerksFlexible Scheduling · Competitive Compensation · Career Advancement · Job Summary · We are seeking experienced home health care professionals/Certified Nursing Assistants (CNA) to join our team. In this position, you will assist pati ...
-
registered nurse critical care
2 weeks ago
TriHealth Cincinnati, OH, United StatesJob Description · Positions available for CVICU and MSICU. Position offers option for Full Time and Part Time roles. Day shift or night shift roles. Sign on bonuses vary depending on shift. · Job Overview: · This position applies the nursing process in providing direct and indir ...
Managed Care Nurse - Cincinnati, United States - Continuum Medical Staffing
Description
Summary of Responsibilities:
Provides concurrent and retrospective utilization reviews, large case management, disability case management and other programs to improve the quality of medical care and control costs. Works with minimal supervision and is responsible to make an established range of decisions, escalating when necessary, and updating manager on a regular basis.
Position Responsibilities:
Selection Criteria:
Work Setting:
Educational Requirements:
Computer Skills and Knowledge of Hardware & Software Required:
Certifications & Licenses (i.e., Series 6 & 63, CPA, etc.):
Position Demands:
Managed Care Nurse professionals in Cincinnati
-
tara chandler
Registered Nurse
-
shakell lester mccoy
I am a Medical Biller and Coder
-
Brian Levins
Child/Adolescent/Adult Psychiatrist
-
Sanjay Rathore
Medical Director
-
Elizabeth Slawnyk
Patient Care Assistant
-
Jaleesa Spencer
Data Entry for AI Development