Medical Services Care Coordinator I/II - RNs and Licensed Behavioral Health Professionals wanted

Company: Excellus BlueCross BlueShield
Location: Buffalo
Posted on: November 19, 2021

Job Description:

PLEASE NOTE: With limited exceptions, our company is requiring all employees to be vaccinated against COVID-19 by Jan. 1, 2022. We also currently mandate vaccinations for employees who enter our buildings. Please keep this in mind when applying for positions at our organization. The Medical Services Care Coordinator is responsible for coordinating, integrating, and monitoring the use of medical and health care services for members, ensuring compliance with internal land external standards set by regulatory and accrediting entities. Refers appropriate cases to the Medical Director for review, identifies billing trends and refers possible medical fraud to the Special Investigations Unit. The Medical Services Care Coordinator may also perform a variety of technical and administrative tasks essential to the efficient operation of the Medical Services Department. Essential Responsibilities/Accountabilities All Levels * Performs clinical review of the appropriateness and quality of medical services, applying guidelines and medical policies and contractual benefits as well as State and Federal Mandates. May perform clinical review telephonically or on-site, depending on customer and departmental needs. * Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical nursing knowledge, coding standards, members' specific health plan benefits, and efficient care delivery processes. Ensures compliance with corporate and departmental policy and procedure, identify and refer potential quality of care and utilization issues to Health Plan medical director. * Utilizes appropriate communication techniques with members and providers to obtain medical information, assesses need for continuation of medical services, assists members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care. * In support of the physician's plan of care, provides care coordination for members who have immediate and long term medical care needs, identifies opportunities to integrate medical and health care services and implements those arrangements. Collaborates with hospital, home care, and other providers effectively to assure that clinical needs are met and that there are no gaps in care. Makes referrals into health promotion and health risk prevention programs as appropriate and member benefits permit. * Acts as a resource and liaison to the provider community, explaining processes for accessing Health Plan to perform medical review, obtains case or disease management support, or otherwise interacts with Health Plan programs and services. * Makes accurate and consistent interpretation of Interqual--, medical policy, contract benefits and State and Federal Mandates and maintains current and working knowledge of Utilization Management Standards. * Performs pricing, coding and or medical necessity reviews prospectively, concurrently, and retrospectively ensuring compliance with internal and external standards set by regulatory and accrediting entities. Researches and adjudicates medical claims and contested cases to assure accurate application of contract benefits and Corporate Medical Policies. * Accountable for meeting departmental guidelines for timeliness, production and metrics and meeting requirements established for Medical Services Audits to ensure adherence to regulatory and departmental policy/procedures. * Maintains compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements. * Assists with training and special projects as assigned. * Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct. * Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. * Regular and reliable attendance is expected and required. * Performs other functions as assigned by management. Level II - similar responsibilities for level I, in addition to the following: * Offers process improvement suggestions and participates in the solutions of more complex issues/activities. * Mentors junior staff & assists with coaching whenever necessary. * Provides consistent positive results of audits. * Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health. * Manages more complex assignments; larger caseloads and a greater number of facilities. * Displays leadership and serves as a positive role model to others in the department. Level III - similar responsibilities for level I & level II, in addition to the following: * Audit - Ensures regulatory requirements such as DOH, CMS and Medicaid, and, accreditation requirements such as NCQA, URAC and HEDIS functionalities of utilization management services relative to patient care are met or exceeded across all lines of business in the day to day work. Serves as internal auditor within the group. * Process Management and Documentation - o Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies. o Assists in updated departmental policies, procedures and desk-top manuals relative to the functions o Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department. * Expert and resource for escalations - Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems. * Liaison role - o Acts as the liaison point person for activity generated by CAU, CS, PR, Sales & Marketing and Monroe Plan. o Primary liaison between the Utilization Management Department and other functional areas. * Mentor (to others in department) - Provides guidance and leadership to the daily activities of the Utilization Management Department clinical staff. Acts as resource to Utilization Management staff, members and providers. * Provides backup for Assigned Management, whenever necessary. Participates in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care. * Responsible for workflow coordination of the group. * Assists Medical Director (MD) in projects at times. * Responsible for all aspects of the Utilization Management department functions including quality, productivity, utilization performance, ROI and educational needs to address established policies and procedures and job responsibilities. Minimum Qualifications Note of Classification We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels * Registered Nurse with current NYS license. Bachelor's degree preferred. * Minimum of three years of clinical nursing background required. * A minimum of one year's recent Utilization Management, Acute Care, Home Care or Skilled Nursing Facility experience. * Must demonstrate proficient experience in use of a computer. Example-creating documents, Word, Excel, Internet and email. * Experience in interpreting health plan benefit plans and strong knowledge of contracts & benefits preferred * Knowledge of CPT, HCPCS and ICD9-CM diagnosis and procedure coding with eventual formal coding education and certification (i.e. CPC, CPC-H, RHIT) when indicated * Strong written and verbal communication skills * Knowledge of InterQual criteria and/or Medicare and Medicaid guidelines preferred. * Ability to multi task and balance priorities. * Must demonstrate work habits sufficient to be able to work independently on a daily basis. * Ability to independently travel. Level II - similar qualifications as level I, plus: * Must have been in a current utilization management position for at least 2 years. If the above is not met, however, transfer to this department either externally or internally should meet all the necessary functions of this level. * Understanding and performing of the Utilizations Management aspects of the job. * Deliver efficient, effective, and seamless care to members. * Understands when to escalate to management. * Be an expert in the technology of the job * Ability to take on broader responsibilities * Ability to participate in training of new staff * Be part of committees and able to lead some committees Level III - similar qualifications as level I & II, plus: * Must have been in a current utilization management position or similar subject expert for at least 5 years * Broad understanding of multiple areas (i.e. UM and CM). At this level, incumbent is required to know multiple functional areas and supporting systems. (BREADTH) * Expertise in Utilization Management area and ability to handle complex assignments, difficult members and highly visible issues. (DEPTH) * Ability to lead the training of new staff. * Demonstrated presentation skills. Physical Requirements 75% sedentary 25% active The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve. Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce. OUR COMPANY CULTURE: Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer

Keywords: Excellus BlueCross BlueShield, Buffalo , Medical Services Care Coordinator I/II - RNs and Licensed Behavioral Health Professionals wanted, Healthcare , Buffalo, New York