Medical Claims Review Associate Analyst

Nurse Case Manager Sr Analyst

Clinical Operations Department

This position through the case management process will promote the improvement of clinical outcomes to members and assist those members experiencing illness and injury. The Clinical Case Manager will assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual’s health needs within case load assignments of a defined population based on business perspectives. The Clinical Case Manager will provide customers and clients with assistance to include  “ Information, Navigation  and  Coordination”  to best  meet the  customers  medical needs with  regards to the covered benefit plan. Assistance may include such activities as providing clinical information regarding medical conditions or treatments, identifying providers and coordinating complex care plans. The Clinical Case Manager will promote quality cost-effective outcomes managing care needs through the continuum of care utilizing effective verbal and written communication skills and a consumerism approach through education and health advocacy to members serviced.  Ability to work independently and effectively communicate to internal and external customers using different channels (videoconferencing and international phone calls)

• Manages/coordinates an active caseload of case management cases by providing Information, Navigation and Coordination to Customers outside the United States.

• →Uses clinical knowledge to assess the treatment plan and goals and identifies gaps in care or risks for readmission or complications.
• →Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare.
• →Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc.)
• →Interfaces with the member, family members/caregivers, and the healthcare team/provider, as well as internal matrix partners.
• →Identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
• →Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
• →Evaluates medical information against criteria, benefit plan, coverage policies and determines medical necessity.
• →Build solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers
• →Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings.
• →Assists Utilization Review as needed/requested.
• →Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
• →Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures

• Nurse Licensure. BSc & MSc Nursing
• Language skills: Fluent reading, writing and speaking English; any additional language is a plus.
• Demonstrated strong organizational and leadership skills.
• Strong interpersonal and communication skills.
• Demonstrates problem-solving and analytical skills.
• Knowledge of utilization or case management, cost containment services, managed care, insurance coverage, and financial management preferred.
• Ability to act as an “advocate” for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements.
• Demonstrates sensitivity to culturally diverse situations, clients and customers.
• Compliant with all accreditations, State, Federal and local mandates.
• Ability to operate personal computer, proficient with Microsoft office products, call center software, and a variety of software.
• Not being under any warning.