Case Manager RN (Registered Nurse) - Auto Accident Division - Norristown, PA
January 11, 2018
Responsible for providing telephonic medical case management for the Auto TCM Department. Reviews treatments plans based on causality and medical necessity. Primary Responsibilities: Ensures accuracy, quality and timeliness of reviews are in accordance with state regulations and departmental policy and procedures and account protocols Ensures all notices are accurate and processed timely in accordance with state regulations and departmental policy and procedures and account protocols Reviews and evaluates all medical correspondence received Identifies that properly submitted treatment plans that quality for authorization are processed in accordance with state regulations and departmental policy and procedures and account protocols Identifies that properly submitted treatment plans that quality for a Medical Director Review (MDR) are processed in accordance with regulations and departmental policy and procedures and account protocols Identifies that properly submitted treatment plans that quality for TCM Negotiation are processed in accordance with state regulations and departmental policy and procedures and account protocols Identifies and recommends Independent Medical Examinations (IMEs), Retrospective Peer Reviews, and referrals to Field Based Case Management (FBCM) as necessary and in accordance with state regulations and departmental policy and procedures and account protocols Identifies approved services appropriate for referral to Cypress Care according to account specific protocols and properly completes the referral according to departmental policy and procedures and account protocols Reviews the claim treatment history with internal and external contacts in accordance with state regulations and departmental policy and procedures and account protocols Evaluates clinical file and ensures treatment is causally related and medically necessary Adheres to cost savings measures and departmental and company-wide Quality Assurance programs Holds to the philosophy and standards of quality as outlined by Procura Management Inc. Adheres to statutory regulations, HIPPA compliance, account protocols and department policy and procedures Generates and processes all AIMS correspondence in accordance with state regulations and departmental policy and procedures and proofreads to ensure accuracy Prepares comprehensive summaries following determinations or after significant activity occurs on the file in accordance with departmental policy and procedures and account protocols Maintains the integrity of RMS system at all times and adheres to all electronic paperless workflows Attends in-service meetings and continuing education seminars as appropriate May act as preceptor for TCMs as directed by management Performs other AIMS Department duties as assigned
Required Qualifications: Valid RN/LPN license Proficient computer skills including typing and Microsoft Office software Excellent communication, interpersonal and organizational skills Professional phone etiquettePreferred Qualifications: 2+ years of related case management experience Understanding of state regulations, managed care and insurance terminologyCareers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you'll fill far more than prescriptions. As a member of one of our pharmacy teams, you're empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.(sm) Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: case manager, case management, medical case manager, RN, LPN, Norristown, PA, Pennsylvania, New Jersey, NJ
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.