Healthcare compliance [h1.location_city]

Position Summary :

Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively manage healthcare costs and improve healthcare program / operational efficiency involving clinical issues

Determines medical necessity / appropriateness Facilitates optimal outcomes Identifies and follow through with continuous quality / compliance opportunities. May also include identification of aberrance's and initiation of corrective action Educates / empowers customers to ensure compliance, satisfaction and promote patient advocacy Optimize total costs Implementation and evaluation of policy based on usage and program directives Educate / empower colleagues at all levels to enable decision making at most appropriate level

Duties :

Nurse Case Manager is responsible for face to face and telephonically assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness.

Develops a proactive course of action to address issues presented to enhance the short and long- term outcomes as well as opportunities to enhance a member's overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.

Through the use of clinical tools and information / data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.

Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.

Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member's level of work capacity and related restrictions / limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.

Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures.

Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Productivity and quality expectations. Work requires the ability to perform close inspection of handwritten and computer generated documents. Work requires sitting for extended periods, talking on the telephone, travel to member's homes and typing on the computer.

Experience

RN with current unrestricted Virginia state licensure required.

3 years clinical experience (for example med surg or behavioral health)

Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

Effective communication skills, both verbal and written.

Education

RN with VA current unrestricted Virginia state licensure required.

Associate's or Bachelor's in Nursing

About US Tech Solutions :

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com () .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.