Medical Management Nurse II

Position Description

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

This position resides in the Medical Management Department. Included in this position are four aspects of medical necessity review; Pre-Authorization, Concurrent Review, Medical Claims Review and Appeals. This position is responsible for managing requests for medical necessity review, applying Milliman criteria to requests, researching new and experimental procedures, interpreting Capital’s Medical Policies and current Medicare Guidelines and doing so within the framework of established policy and procedures of Capital’s Clinical Management Department.

Responsibilities and Qualifications

• Responsible for maintaining unit service level goals.
• Determines medical necessity and appropriateness of the service requested or incurred by reviewing the member’s Clinical information, utilizing established criteria to determine appropriate course of action.
• Determines when collaboration with the Medical Director/Associate Medical Director is necessary to decide appropriate course of action.
• Determines when it is necessary to communicate with the provider staff any determinations related to the requested service.
• Communicates any concerns to the Senior Team Lead for follow up and resolution.
• Educates providers on the medical management process for Capital. Identifies knowledge deficits in the Provider Network and refers targeted providers to Provider Relations and Network Management for education, as appropriate.
• Identifies and refers Members with complex needs to the appropriate Clinical Management programs.
• Identifies and refers Members with Potential Quality of Care issues to Quality Management through the PQI Referral Form and any Quality of Service issues to Customer Service for follow up.
• Complies with both internal policies and external regulatory requirements regarding member confidentiality.
• Complies with documentation standards.
• Complies with CMS, NCQA, ERISA and PA. Act 68, and other state and federal regulations and timeliness standards.
• Offers suggestions for improvement in departmental processes and identifies opportunities for new knowledge and approaches.
• Attends and participates in company and departmental meetings and training sessions as required.
• Assists in the orientation and mentoring of their peers.
• Practices within the scope of his or her license and/or certification.

Skills:

• Ability to critically think through processes so as to problem solve and make clinically appropriate decisions daily.
• Successfully work independently and as part of a team.
• Actively and proactively interact with other departments, as needed, to advise, educate and/or direct Members to appropriate internal services.
• Demonstrates openness, flexibility, problem solving, patience, and tact when dealing with Members, family, providers and their peers.
• Demonstrated ability to communicate in a concise and clear manner in both written and oral communications.

Knowledge:

• Working knowledge and operation of a personal computer (PC), including proficiency in Microsoft Word and Access.
• Knowledge of ICD-9-CM, CPT and HCPCS coding.
• Knowledge of Act 68, NCQA, ERISA and CMS regulations.
• Knowledge of managed care principles and emerging health treatment modalities.

Experience:

• A minimum of 5 years clinical experience working in an acute care hospital setting, and preferably 2 years of managed care/preauthorization experience.

Education and Certifications:

• Must be currently licensed as an RN in the Commonwealth of Pennsylvania.

 

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.     And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.