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RN Case Manager

Company: Generali Global Assistance
Location: Pembroke Pines
Posted on: May 5, 2022

Job Description:

Secures and reviews clinical data received in order to approve requests for admissions, procedures and services that meet the clinical review criteria. Ensures that there is coordination of care between all providers involved. Ensure that procedures / services are not duplicated and that services being rendered fall within the industry standards of care. Adheres to the 5 Rights Principal Duties and Responsibilities

  • Performs Utilization Review and Case Management duties according to company policy and procedure
  • Collects client data and conducts emergent and non-emergent clinical assessment
  • Assists in the referral of patients to most appropriate provider specialty / facility within network
  • Monitors and screens pre-authorization requests for second opinion referrals and/or diagnostic testing
  • Reviews hospital admissions for medical necessity and assigns LOS in accordance with established criteria
  • Sends out appropriate letters of certification to pertinent providers, facilities and/or client
  • Refers all cases that do not fall within pre-established criteria to Team Lead for determination of admission approval, procedure or services requested
  • Once it is decided that an admission, procedure or service should be denied; assists in assuring that verbal or written denial notices are distributed out to the appropriate parties in a timely manner
  • Performs duties of the discharge planning nurse to contain LOS and assure that the insured (patient) is receiving services within the 5 Rights (Care/Place/Time/Provider & Price)
  • Assist with the coordination (within all phases) of a repatriation /evacuation and work in accordance to individual Client Procedures as well as internal GMMI work instructions. Report any change in insureds (patients) condition IMMEDIATELY in order to make any differing change in plans
  • Enters and maintains all applicable information related to a case in GMMI's operating software
  • Attends and participates in all department meetings as scheduled. Coordinates data collection and reporting for meetings, as deemed appropriate
  • Evaluates and reviews treatment plan for consistency of care. Develops realistic treatment plan in conjunction with provider recommendations in order to meet the client's needs while providing the most appropriate and cost effective method of delivering services
  • Performs written and oral communication with other GMMI staff to provide case information, recommendations based on medical necessity and policy language and cost indexes to clients
  • Evaluates and determines the availability of resources in conjunction with policy limits and coverage
  • Implements cost management and delivers the most effective treatment plan.
  • Maintains current knowledge base with regard to medical-surgical cases, utilization management, discharge planning and continued care needs in relation to physician approved criteria. Case Manager is to expand knowledge base and become familiar with ICD-10 and how this will change and improve cost containment efforts in the future
  • Reports concerns, problems, and quality assurance issues to department head for evaluation. Follows up with corrective action on recommendations made when required
  • Responsible for updating the "Tracker" System for any Client that has this option available and responsible for timely follow up on each case as monitored by the tracker
  • Participates in issuing non-conformance and corrective actions as per ISO policy when quality issues or breaks in services or systems are identified (always think proactively) Required / Desired Knowledge, Experiences and Skills:
    • Prior to being employed by GMMI, Case Managers need to possess at least two years experience in the field of Managed Care or related areas (Medical/Surgical, OB/GYN, Pediatrics, Cardiology, Neurology, Nephrology, Orthopedics, Transplant or CCU/ICU)
    • Maintains confidentiality of all pertinent client/patient information
    • Basic to moderate computer literacy required
    • Basic to moderate typing competency required
    • Strong organizational and time management skills required - with emphasis on prioritizing and performing multiple tasks in unison
    • Excellent communication skills (verbal and written)
    • Effective and sound decision making and problem solving skills a must
    • Ability to work both independently and in a group setting
    • Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds' as deemed necessary
    • Able to work in a multicultural environment and manage a diverse client / patient population is required
    • Bilingual (any language) preferred Education/Certifications:
      • Bachelor's Degree required
      • Licensed and/or certified health professionals (LPN, LCSW or RN)
      • Active license in the state of Florida
      • Keep license current and complete CEU's as mandated by the Board of Nursing in the state of Florida http://floridasnursing.gov/ or Board of Clinical Social Work in the state of Florida http://floridasmentalhealthprofessions.gov/licensing/ Physical Working Environment:While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified. GMMI is an Equal Opportunity Employer M/F/Disability/Veteran

Keywords: Generali Global Assistance, Pembroke Pines , RN Case Manager, Executive , Pembroke Pines, Florida

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