Medical Review Nurse

Details
Type: Continuous Recruitment

Requirements

Current, unrestricted Wyoming license as LPN, RN or APRN. Bachelor’s or Master’s degree in nursing preferred. Certified Case Manager (CCM) required for Case Management positions. No experience to three years of experience in case management, disease management, health care or health insurance.

General Purpose

Registered Nurses are hired from various professional disciplines, education and experience backgrounds for the purpose of ensuring a pool of talent for future staffing needs. As dictated by the needs of the company, duties of the Registered Nurse may fall under any of the following categories.

Utilization Management – Evaluate appropriateness of health care services based upon medical knowledge and condition of patient. Application of benefits available through the individual or group health policy as they relate to the patient’s medical condition. Research new procedures for determination of coverage.

Case Management – Review cases of members with acute or chronic conditions and collaborate with providers, the patient and family, and internal resources to establish the most effective treatment plan within the provisions of the health policy. Screens, assesses and develops case recommendations; educates patients and family; coordinates with providers and monitors and documents cases on an ongoing basis.

Disease Management – Provide population-based approach to the clinical and quality management of chronic conditions. Identify individuals with chronic conditions, and through use of disease-specific interventions, attempt to alter the course of the disease.

Essential Duties & Responsibilities

Utilization Management

  • Work toward quality initiatives.
  • Review and research cases to make determination by utilizing appropriate medical policies and medical records.
  • When appropriate, refer cases for further review.

Case Management

  • Work toward quality initiatives.
  • Identify and assess members with conditions that may require intervention.
  • Utilize health policy and collaboration to develop a care plan, educate member and providers and monitor for compliance and ongoing need.
  • Participate in discharge planning and make referrals to appropriate resources.
  • When appropriate, refer cases for further review.
  • Document all case information in accordance with applicable policies and standards.

Disease Management

  • Work toward quality initiatives.
  • Utilize stratification tool and data to perform disease management outreach and monitor clinical program effectiveness.
  • Facilitate communication with member and providers and coordinate referrals.
  • Document care focusing on specific treatment goals in accordance with applicable policies and standards.
  • Assess adherence and progress with plan. Modify as necessary to remove barriers to self-management of chronic conditions.
  • Provide education, resources and referrals to patient and family.
  • Monitor HEDIS measurements and implement corrective action plans as needed.
  • When appropriate, refer cases for further review.

Other Duties & Responsibilities

  • Practice within scope of licensure and the Wyoming Nurse Practice Act.
  • Work in conjunction with medical staff under the direction of the CMO.  Receives clinical oversight from CMO in accordance with policies and procedures.
  • Keep member Personal Health Information (PHI) confidential.
  • Interact well with other departments.
  • Adhere to appropriate guidelines and laws applicable to duties (e.g. HIPAA, ERISA, CCM, URAC)
  • Other duties as assigned
Supervisory Duties

None.

Job Qualifications

Knowledge, Skill & Ability
  • Sound general nursing background.
  • Display ability and desire to work with supervision and remain completely informed with a broad general knowledge of related work.
  • Computer literacy and the skill required to execute the function.
  • Professional phone and communication skills.
  • Good organizational skills and ability to multitask.
  • Ability to balance the demands of multiple tasks and deadlines.
  • Ability to attain a specialized knowledge of benefit structure, corporate procedures and polices relative to claims processing.
  • Ability to attain in depth knowledge of existing health insurance contract benefit structures and payment processes.
  • Ability to develop and maintain professional relationships.
Education, Licensure, or Formal Training
  • Current, unrestricted Wyoming license as LPN, RN or APRN.
  • Bachelor’s or Master’s degree in nursing preferred.
  • Certified Case Manager (CCM) required for Case Management positions.
Experience

No experience to three years of experience in case management, disease management, healthcare or health insurance. Job placement will be determined based on education and work experience.

Equipment & Environment

Material & Equipment Directly Used

Computer, electronic health care processing software, Microsoft Office, various on-line software, fax, copy and scanning machines, telephone

Working Environment / Physical Activities

Works in an open office environment. Physical activities include, but are not limited to, keyboard and mouse manipulation, hand carrying items short distances to various other departments.

Access to Protected Health Information (PHI)

Access to Protected Health Information (PHI) will be limited to that which is necessary to carry out job duties outlined above.

Notes & Other Information

Position summary shown may not include ALL of the necessary knowledge, skill, and ability requirements.

Note: Position summary shown may not include ALL of the necessary knowledge, skill, and ability requirements.

Blue Cross Blue Shield of Wyoming
EOE M/F/Vet/Disabled Employer
E-Verify

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