GENERAL OVERVIEW
Coordinates patient progress toward achieving quality and cost outcomes; mobilizes resources and manages the system in response to concurrent variances according to the pre-established standards.
ESSENTIAL RESPONSIBILITIES
Responsible for utilization management. (50%)
Communicates and collaborates with physicians and multidisciplinary teams to ensure appropriate management of resources to attain patients individualized goals in an appropriate and timely manner and appropriate setting. (30%)
Implements an effective discharge plan. (20%)
QUALIFICATIONS
Minimum
Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
5 years acute Medical/Surgical and/or specialty care nursing required.
BA/BS degree and Nursing school diploma required
Preferred
Experience in utilization management and/or employment by a third party payor/review agency preferred.
Additional Employment Requirements:
CPR – American Heart Association
Act 34 Criminal Background Clearance Certificate
Act 33 Child Abuse Clearance Certificate
Act 73 FBI Fingerprinting Criminal Background Clearance Certificate
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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