Medical Claims Review Nurse Case Manager

Reviews hospital and professional claims exceeding specified thresholds to identify billing errors, excluded services (such as experimental or investigational services), unbundled services or services discrepant with concurrent review information. Refers cases to Medical Director for review as appropriate. Completes reviews within department established turn-around times to avoid payment of interest on claims. Communicates with and assists the Claims Department in processing complex claims. Will ensure proper utilization of services and resources, medical bill cost assessment and cost containment. Will provide direct assistance to the underwriting and actuarial departments for new and renewing group underwriting requests. Coordinates with the Health Services staff as needed and indicated for clinical documentation and/or additional information/support.

Responsibilities:

Reviews clinical documentation to ensure appropriate coding and reimbursement for high dollar claims. Demonstrates ability to effectively and efficiently research current usual and customary billing for procedures, diagnostics, inpatient stays, etc.

Responds quickly and efficiently to requests for review of future claims costs relative to the clinical presentation of members for new and renewing groups. Demonstrates a knowledge of understanding of how to effectively research and predict future claims costs.

Back up for Health Services functions regarding Appeals and Grievances.

Collect and assess member information pertinent to member’s history, condition, and functional abilities in order to develop a comprehensive, individualized care plan that promotes wellness, appropriate utilization, and cost-effective care and services.

Develop, implement, and coordinate case management action plan for achieving specified member goals as determined by the case management plan. Coordinate necessary resources to achieve goals and objectives. Accurately document case notes and letters of explanation which may become part of legal records.

Monitor and evaluate appropriateness of case management action plan, assess progress toward meeting goals, and modify the plan to help achieve desired member outcomes.

Perform concurrent review of members admitted to hospitals. Maintain telephone contact with the hospital utilization review personnel to assure appropriateness of continued stay and level of care. Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, home health or hospice services.

Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.

Identify and negotiate with appropriate vendors to provide services. When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development.

Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues.

Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.

Assist Medical Director in developing guidelines and procedures for the Health Services Department.

Supporting Responsibilities:

Act as backup for other Health Services Department staff and functions as needed.

Serve on designated committees, teams, and task groups, as directed.

Represent the Heath Services Department, both internally and externally, as requested by Medical Director.

Meet department and company performance and attendance expectations.

Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

Qualifications:
Five years of nursing experience with varied medical exposure and experience preferred. Medical claims review experience preferred. Certified coder or willingness to obtain certification within 2 years of hire. Prior claims review experience and expertise in underwriting preferred. Experience in acute care, case management, including cases that require rehabilitation, home health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Must have an overall understanding of utilization management and claims costs.

Education, Certificates, Licenses: Registered Nurse with current unrestricted state license. Oregon, Idaho or Montana license required at time of hire. Bachelor’s degree in nursing, business, business administration or healthcare administration strongly preferred.

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD 10 and CPT Codes, health insurance and state-mandated benefits. Expertise in claims review and/or performing underwriting requests. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. Must be able to function as part of a collaborative, cohesive team.

Competencies

Our Values

Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards

We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for our customers’ experience.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our communities-internal and external.
We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Physical Requirements: Stoop and bend . Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.