Clinical Resources Nurse
Summary Description:
The Clinical Resources Nurse (CRN) requires the abilities and knowledge of a California-licensed Registered Nurse (RN)or Licensed Vocational Nurse (LVN). Specifically, the CRN reports directly to Western Health Advantage’s (WHA) Utilization Operations Director (UOD), and works closely with WHA’s Chief Medical Officer (CMO), Assistant Medical Director (AMD), and Clinical Pharmacists to ensure that Utilization Management (UM) review functions are carried out effectively at the corporate health plan level. The CRN may work with Member Services, Claims, Finance, and Sales/Marketing representatives to assist with benefit interpretation, transition of care and out of area care needs, and to provide Clinical Resources assistance as needed. The CRN also assists with the wellness programs to provide clinical support for internal and external health plan wellness promotion activities. The CRN assists Quality Improvement (QI) staff with potential quality issue screening. In addition to working with internal staff, the CRN routinely interacts with representatives from contracted IPAs/Medical Groups to ensure timely access to care, assist with benefit interpretation, treatment for Plan members and coordination of care. The CRN also evaluates and performs utilization review of non-network emergency/urgent hospital admissions, transfers and facilitates the provision of appropriate services through effective collaboration with all stakeholders. It is important to note that routine utilization and case management functions are delegated by WHA to its contracted IPAs, Medical Groups and other carve-out entities.
Representative Duties:
Perform research, evaluation and case preparation of complex requests involving new technology and experimental treatments.
Provide direction and coordination to Intake Coordinators and collaborate with the CR Intake Supervisor.
Assist MSR’s and IPA/Medical Group UM staff with interpretation of benefits, eligibility requirements and regulatory compliance issues re: UM processes for Commercial members.
Review pre-service requests that the health plan holds financial risk for to verify eligibility, ensure services are medically necessary and coordinates with provision by contracted providers or negotiates letter of agreement when needed.
Perform telephonic concurrent review of members admitted through the ER to Out-of-Area (OOA) hospitals, provides care management assistance and coordinates services with Med Group review staff as needed (i.e., works with hospital discharge planners and Med Group nurses to ensure smooth transfers, appropriate discharges, in-network follow-up care/services, etc.).
Provide Continuity of Care (CoC) screening and assistance for new qualified members with transition issues (i.e., for new members with certain acute/chronic care needs and for members with a terminating physician or Group to avoid interruption of medical treatment/services).
Research, review and when indicated, prepare cases for CMO or AMD review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters, etc. (e.g., OOA second opinions, organ transplants, cancer clinical trials, new technology/experimental determinations, etc.).
Assist UOD in the development and provision of educational materials and information for WHA staff and delegated IPA/Groups related to Plan benefits and UM/CM processes.
Assist in maintaining a current quick reference document for review staff by updating WHA’s Prior Authorization and DME Benefit Matrix.
Assist with DMHC regulatory and NCQA accreditation audits.
Actively participates in delegation oversight audits and clinical chart abstractions for assigned medical groups.
Serve as a liaison and resource to assigned medical group staff for questions and assistance.
Provide clinical support for sales, marketing and wellness department activities as needed – including developing or reviewing written materials, presentations and or activities.
Coordinate with QM staff to ensure screening of cases identified as possible Potential Quality Issues.
Initiate and follow up on members identified for referral for Case Management, Disease Management and/or Behavioral Health services.
Provide care coordination, education and support for members undergoing transgender surgery services.
Perform other duties and special projects as assigned.
Qualifications:
Bachelor’s Degree in Nursing.
3 years’ experience in clinic, 1 year in utilization/case management, discharge planning and/or 1 year in managed care environment.
Valid Registered Nurse (RN) License or Licensed Vocational Nurse (LVN) is required prior to employment and must be maintained for the duration of employment.
Utilization Management, Quality Management, or CCM certification a plus but not required.
Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, the ability to create formulas and graphs in Excel and import them into Word documents.
Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Salary:
$85k -$115K Annually
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.