Care Coordination Nurse I

Job Description:

• Assess members’ status by collecting in-depth patient information and identifying needs
• Develop and implement comprehensive disease management plans with specific objectives, goals, and actions
• Implement interventions to accomplish established goals
• Coordinate, organize, integrate, and modify resources needed to accomplish goals
• Monitor plans by gathering information and evaluating effectiveness
• Meet staff and unit performance targets and department productivity goals
• Perform care coordination or Utilization Management as designated by RN and/or clinical leadership
• Research and interpret contract benefits to facilitate accurate benefit administration and product-specific authorization requirements
• Conduct medical necessity reviews using accepted criteria, guidelines, medical delegations, and policies
• Review, resolve, and respond to utilization-of-benefits issues and coordinate appropriate care
• Negotiate payment rates when provider network deficiencies exist
• Calculate and document care management savings, identify product enhancement opportunities, and capture ROI
• Communicate with members and providers regarding contract requirements and collect planned-care information by telephone
• Manage verbal notifications and written materials in compliance with regulatory and operational guidelines
• Serve as a technical resource to non-clinical staff by interpreting clinical information
• Perform other job-related duties within scope of responsibilities

Requirements:

• High School Diploma or equivalent required
• 4 years of direct patient care experience required
• Managed Care or claims processing experience
• Knowledge of medical terminology and ICD-10 codes
• Current, unrestricted LPN license in Louisiana and/or required jurisdictions where services are provided
• CPUR, CPC, or CMCN certification preferred upon hire and required within 24 months in position
• Knowledge of insurance, reinsurance, and/or customer service operations preferred
• Ability to research and analyze cases and make quality and cost-effective decisions
• Effective communication with members, providers, pharmacy staff, and employees at all organizational levels
• Detail-oriented, organized, and self-motivated
• Professional judgment and ability to make decisions and delegate work appropriately while managing multiple tasks
• Working knowledge of related software and office equipment
• Ability to comprehend Medicare guidelines and assume responsibility for guideline-based decisions
• Knowledge of ICD, HCPCS, and CPT coding guidelines preferred
• Ability to work in the United States without employer-sponsored immigration support
• Residency in or relocation to Louisiana preferred

Benefits:

• Employee resources to live well, be healthy, continue learning, develop skills, grow professionally, and serve local communities
• Reasonable accommodations for individuals with disabilities
• Smoke- and tobacco-free work environment
• Pre-employment drug screening and background screening