| As a part of the Tenet and Catholic Health Initiatives family, Conifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance for more than 600 clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communications, and value-based care solutions, we empower healthcare decision makers-hospitals, health systems, physicians, self-insured employers, and payers-to better connect every point of care and wellness management. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
POSITION SUMMARY
IMMS uses a holistic approach to medical management. Therefore, although they may perform separate functions, the Personal Health Nurse (PHN) and Utilization Management Utilization Management Nurse (UMN) work within a team to move the participant through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means. The PHN performs the Personal Health Management process, that is assesses the participant, works with the participant, family and physician to identify problems, establish goals and develop plans of care, coordinates services, educates participants, empowers participants to independently self-manage and to make knowledgeable health care decisions. The UMN provides utilization review/pre-certification or pre-notifications on various individuals under designated group health contracts. Both the PHN and UMN work closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s). Both perform some functions of Personal Health Management and Utilization Management. Additionally, they interface with clients and with IMMS account managers and are responsible for the medical management of designated account(s). Within this description, the title �Medical Management Nurse: refers to both. All Medical Management Nurses practice within the scope of their licensures.
Qualifications:
EDUCATION AND/OR EXPERIENCE REQUIREMENTS ATTENDANCE Ability to adhere to attendance policy as Position requires consistent attendance MINIMUM PHYSICAL REQUIREMENTS Speaking: Expressing or exchanging ideas by means of the spoken word. This includes activities in which the reviewer must accurately and concisely convey detailed instructions or abstract concepts to clients, other employees, and audiences. Hearing: Ability to receive, process, understand and act upon complex materials through spoken language Lifting: Moving moderately weighted objects from one position to another Ability to enter/retrieve data on personal computer as position requires extensive use of computer Sedentary work in the office
COMPETENCY PREREQUISITES Current active professional license in the state of residence Eligibility for unrestricted professional licenses in all states Competency in Microsoft Word Competency in using email, attachments Excellent verbal communication skills with the ability to communicate with participants and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, account managers, brokers, customer service staff, IMMS executive management, other IMMS Medical Management nurses, hospital utilization review nurses, etc. Excellent written communication skills with the ability to write in a professional, business manner Ability to analyze and resolve complex problems Excellent organizational and prioritization skills Excellent time management skills Ability and willingness to function as part of a team Ability and willingness to function independently Flexibility and willingness to change Understanding of IMMS holistic approach to medical management Understanding of the client�s (customer�s) perspective and needs Understanding of legislative acts, such as the ADA
PERFORMANCE Competency Performance Rating-Self Performance Rating Complies with laws and regulations that govern the medical management services. Adheres to IMMS Policies and Procedures Follows Policies and Procedures for Personal Health Management and utilization management Understands of IMMS holistic approach to medical management Understands the client�s (customer�s) perspective and needs Adheres to of the CMSA Standards of Practice Advocates for participant to obtain quality health care Identifies liability issues associated with the performance of medical management Adheres to CMSA Standards of Practice and Professional Code of Ethics Understands legislative acts, such as the ADA Understands purpose of URAC knows how to access the standards Uses Milliman Care Guidelines Competency with InforMeds� Web-based products as they relate to Medical Management, including referrals, Clinical Claims Chart, EBM, Risk Stratification, etc.
Competency Knows how to access and uses the Summary Plan Descriptions (SPD) Functions independently Demonstrates flexibility and willingness to change Provides and documents proactive medical management interventions Assesses and documents clinical and behavioral outcomes Identifies and documents financial outcomes according to InforMed�s standards Consults with IMMS Medical Director on issues of concern about participant treatment plans Refers all participants who have a patient severity of �high� to Personal Health Management Triggers participants for review Reviews participants as triggered Documents thoroughly, that is completes each component of documentation, such as treatment plan, diagnoses, cost savings Documents objectively, succinctly, and in accordance with IMMS guidelines Bills for activities appropriately Enters billable time into �Activities� that accurately reflects all participant specific activities Enters billable time into �Analytics� for non patient specific activities Under direction of TL, manages accounts using the 4-Pronged approach Expected number of billable hours are met Completes MMOTS protocols as appropriate Uses MMOTS tools Offers assistance to team participants when needed and/or as time allows Requests assistance from team participants when needed Attends staff meetings Attends staff training Obtains at least 8 CEUs per year and documents CEUs on educational log Applies for certification if eligible Arranges coverage for accounts when planning PTO
Personal Health Management Specific Competency Reviews daily calendar for new episodes and tasks due Prioritizes tasks listed on calendar Adheres to IMMS indicators Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the participant and the physician�s assessment and treatment plan Determines and documents participant�s goals
Personal Health Management Specific Competency Engages the participant in the personal health management process Engages the PCP and treating physicians in the personal health management process Collaborates with the participant and PCP in development of an individualized plan of care Develops an ongoing individualized plan of care with timeframes, reasonable and appropriate expected outcomes, specific planned interventions and participant�s goals Follows through with interventions and documents outcomes in Current Clinical Status section of care plan Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity Closes episodes as indicated, i.e. evaluates �Impactability� among other indications for closure.
Utilization Management Competency Reviews daily calendar Reviews inpatient episodes and obtain clinical as needed Reviews accounts for pre-service requests Determines priority of pre-service request Complies with and document all pre-service time lines Refers requests that cannot be approved to the Medical Director Confers with Medical Director for any case of concern regarding treatment patterns or pre-service request. Generates adverse decision letters to the affected provider and participant Attaches all documents submitted by the provider to support medical criteria for approval of the pre-service claim Provides telephonic notification of adverse decision on a pre-service request within policy guidelines. Determines appropriate review strategy as identified by the various group health contracts: Preadmission review; Concurrent review; Retrospective review; Pre-certification/Pre-notification Identifies and utilizes the applicable utilization review/management tools, while performing pre-certification/pre-notification/clinical reviews: Milliman Care Guidelines; ETGs� Ensures and coordinate participant services are at lowest level of service that meet the participant�s needs Promotes efficiency of hospital/provider services Promotes discharge planning
Job: Nursing Primary Location: Frisco, Texas Job Type: Full-time Shift Type: Days
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