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Experience:
1-3 years of experience
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Employment Type:
Full time
Posted:
7/16/2015
Job Category:
Health Care Provider
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Care Manager II-Prior Auth - TELECOMMUTING OPTION! (AZ: Tempe)
Health Net, Inc. | Tempe, Arizona
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Job Description

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Job Summary

The Care Manager II –Pre-Service Review/Prior Auth performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary services requests, exclusive to a Medicare population. Reviews include medical appropriateness and medical necessity determination requiring considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures and clinical guidelines. Acts as liaison between the beneficiary and the network provider and HN to utilize appropriate and cost effective medical resources.

 

 

 

Essential Duties & Responsibilities

  • Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans. Makes first level approval determinations when appropriate.
  • Reviews, triages and prioritizes cases to meet required turnaround times. Expedites access to appropriate care for members with urgent or immediate needs using expedited review process.
  • Performs research and analyzes complex issues, assesses member needs. Acquires appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy. Accurately applies coding guidelines.
  • Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors.
  • Using professional judgment, independent analysis and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc to case review.
  • Summarizes case including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.
  • Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.
  • Develops determination recommendations and presents cases to Medical Director for potential denial determinations or when Medical Director input is needed.
  • Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
  • Develops and/or reviews appropriate documentation and correspondence reflecting determination. Assures accuracy, completeness and conformance to standards.
  • Documents all activities as per unit practice including entry into automated systems. Recognizes potential quality care concerns and refers as appropriate.
  • Identifies and refers members who may benefit from disease management or case management and makes appropriate referrals.
  • Identifies potential TPL/COB cases, investigate TPL/COB issues and notifies the appropriate internal departments.
  • Manages out of area cases/requests based on current policy.
  • Conducts rate negotiation, when necessary and as per policy, with non-network providers, utilizing appropriate reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication.
  • Coordinates UM/CM review activities with delegated entities when applicable.

 

Education

 

  • Graduate of Nursing program, BSN Degree preferred.

Certification/Licensure Required

Active, valid, maintained & unrestricted state of AZ Registered Nurse license REQUIRED.

Government Clearance & US Citizenship Requirement

N/A

Experience Required

Minimum two years clinical experience.

Minimum two years managed care experience, including discharge planning, Case  Management, Utilization Management, Home Health or related experience required.

Health Plan experience preferred

Health Plan Prior Auth clinical experience preferred

 

 

 

Knowledge, Skills & Abilities

Knowledge, Skills & Abilities:

  • Strong knowledge of NCQA, federal and state regulations/requirements.
  • Demonstrated ability for assessment, evaluation and interpretation of medical information. Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs.
  • Strong analytical and problem solving skills preferred. Excellent verbal and written communications skills. Excellent case preparation and abstracting skills. Team player who builds effective working relationships.
  • Ability to work independently. Experience using standardized clinical guidelines/criteria required. Strong organizational skills.
  • Able to operate PC-based software programs including proficiency in MS Word.
  • Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations.

 OR

 

Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.

 

 

 

 

 

 

 

 

 

Working Conditions

  • The following section describes the general physical requirements for this position.  Please note that ‘constant’ refers to more than 81% of time; ‘significant‘ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.
  • Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
  • Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
  • May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
  • May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
  • Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
  • Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
  • Required to have hearing ability to receive detailed information through oral communication.
  • Required to have speaking ability to express or exchange ideas.
  • Constant concentration may be required on various subjects by listening, reading and thinking clearly.
  • Interaction with others may be required.  May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required.  This may require face-to-face or telephone interactions.
  • Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
  • Constant computer usage including typing and/or eye strain.
  • Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
  • Constant phone usage; headsets may be required.
  • Moderate lifting may be required.  May need to lift, carry and/or move equipment/supplies weighing up to 20 pounds, always using safe lifting techniques.
  • Constant sedentary work (desk bound or seated).
  • Constant reading is required via computer screen and/or bound printed materials.
  • Moderate walking/standing may be required.  Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.

Disclaimer

DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.

Location:

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Veterans/Disability

 

 

About Health Net, Inc.

Health Net, Inc. (Health Net) is an integrated managed care organization that delivers managed healthcare services through health plans and government-sponsored, managed-care plans. The Company operates and conducts its businesses through its subsidiaries. Health Net's health plans and government contracts subsidiaries provide health benefits through its health maintenance organizations (HMOs), insured preferred provider organizations (PPOs) and point-of-service (POS) plans to approximately 6.7 million individuals across the country through group, individual, Medicare, (including the Medicare prescription drug benefit commonly referred to as Part D), Medicaid, TRICARE and Veterans Affairs programs. The Company operates within two segments: Health Plan Services and Government Contracts. (Source: 10-K)

This company profile was created by AfterCollege and is about Health Net, Inc.. This page is not endorsed by or affiliated with Health Net, Inc.. For questions regarding company profiles, please email: care@aftercollege.com.