Job #: 2547
Title: Nurse Manager
In conjunction with the Director of Healthcare Programs and the Chief Medical Officer, this position includes, but is not limited to, review and tracking of member assessments for homecare services, management of the utilization and case management programs for the PHP Medicaid product and participation in other healthcare programs such as telemedicine and proactive and prevent care services at the discretion of the Director.
Duties and Responsibilities:
Assist the Director of Healthcare Programs in the development of a program to assess members that require PCA or CDPAP services
Reengineer the overall management processes including scheduling, use of the assessment tool, productivity standards, writeup requirements and resolution process
Define the review process of assessments to insure standard outcomes and quality reports among assessment nurses
Define process for interactions between care managers and assessment nurses based on I AM and assessment outcomes to arrive at a consensus outcome
Develop process and template for presenting information to medical director based on disagreement of reduction in hours or the member appeal process
Assist in developing program reports
Manage the staff and program designed to provide member assessments for PCA and CDPAP programs
Define and develop a utilization management program in conjunction with the Director of Healthcare Programs and Chief Medical Officer for members of PHP’s managed Medicaid and SIP-PL products with regard to first level clinical review for DME and ancillary services requiring prior authorization using appropriate criteria.
Define support staff necessary to successfully implement and run program
Develop process for interaction between utilization management team and case management team for managed Medicaid and SIP-PL products
Manage the utilization management program and staff for the managed Medicaid and SIP-PL products
Work directly with clinical pharmacy vendor HMetrix as to insure appropriate implementation of the Clinical Pharmacy Program for care transitions and polypharmacy for the managed Medicaid and SIP-PL products.
Work with the Clinical Quality Management Department to provide appropriate information to meet defined quality program needs and to identify all potential quality issues related to the PHP Medicaid product
Participate in and/or facilitate internal weekly in-patient case review meetings.
Serve on various internal committees including: Quality Management, and UM Review.
Assist Training Department in enhancing staff training programs with regard to member assessments and utilization management
Participate in process reviews and the development of new and/or revised workflows, policies and procedures relating to utilization review and care management support for members based on program outcome reviews
Act as a liaison with outsides entities as needed, including, but not limited to, physicians, hospitals, health care vendors, social service agencies, member advocates, regulatory agencies at the request of the Director of Healthcare Programs
Participate in other Healthcare Programs such as telemedicine and proactive care management at the discretion of the Director of Healthcare programs
Licensed LPN or RN in state of New York
Bachelor’s Degree required; BSN preferred
Experience in managed care utilization review (5 years minimum); full working knowledge of Medicare and Medicaid systems
Experience in the UAS process and the use of tasking tools (5 years minimum)
Management experience regarding utilization management programs, both Medicaid and Medicare including the appeals process
Management experience with regard to the use of assessment processes, tasking tools with regard to Medicaid including the appeal process
Prior experience in working to support a special needs population preferred
Experience working collaboratively with various departments in fast-paced environment
Experience in utilizing decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
Proficiency in working within electronic health record systems; computer skills
Strong communication and interpersonal skills
Requirements for All Positions:
All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
Improve health outcomes;
Prevent hospital readmission;
Improve patient safety and reduce medical errors, and
Provide wellness and health promotion activities.