Concurrent Care Coordinator Jobs (NOW HIRING)

This position is accountable for developing, coordinating, and administering all activities related to the Comprehensive Managed Care Program. Activities involve effective communication with all members of the health care delivery system, group representatives. Utilization review activities may include prospective, concurrent, retrospective and appeals reviews. Individual patient assessment, and coordination of case management activities are additional responsibilities. The incumbent coordinates case activity and maximizes the patient's contract benefits by evaluating the patient's needs and developing alternative plans of treatment that provides quality care.

For Utilization Review, work is received via telephone, facsimile, Internet, or mail from providers. Case management functions are initiated through referrals from hospitals, physicians, groups, agencies, Blue Cross and Blue Shield internal sources, and/or patient or family members. The incumbent performs reviews of procedures and diagnoses for medical necessity of place of treatment in order to determine benefit coverage for admissions or continued stays, and to determine the appropriate level of care for proposed services. The incumbent also analyzes the patient's contract benefit structure during the review. The incumbent identifies potential patients who would benefit from case management. During the initiation of the case management process the incumbent reviews the physician's plan of treatment in order to evaluate the patient's status and needs, and may do an on-site evaluation. The incumbent develops a plan of treatment that maximizes benefit coverage and quality of care. The plan may be based upon regular benefits or alternative benefits. The plan of care includes cost projections and an evaluation of the plan with the physician, patient and family, and the group. The plan of care calls for contractual arrangements to be set up with providers, patient and family. At the request of providers/ subscribers, the incumbent reviews non-certified claims on appeal and makes determinations with the assistance of a peer clinical reviewer or medical director, if necessary. If a problem has not been addressed by guidelines, the incumbent researches and recommends guides. Periodically, cases are reviewed and assessed, and treatment plans are revised or improved as necessary. The incumbent may provide periodic reports to the Group.

The incumbent has a thorough understanding of medical services, which is based on clinical experience. The incumbent must know benefit guidelines, claims payment guidelines, billing guidelines, laws and contracts that govern the health insurance programs administered by the corporation. As a representative of the corporation, the incumbent must utilize acquired job knowledge as well as be able to defuse situations and solve problems. Examples may include performing reviews of patients' care in hospitals or meeting with the hospital administration, providers, legal representatives, patient and family. Accurate documentation is critical and requires that summaries of all personal and telephone contacts must be kept in the case file. The incumbent must have the ability to meet and effectively communicate with all levels of management, possess mature judgment and sense of discretion, memory for details, and ability to resolve problems independently. The incumbent must maintain current knowledge of UM/URAC principles that are applicable to their job. The incumbent must adhere to the confidentiality and conflict of interest policies as set forth by the division and corporation. Active license as a Registered Nurse (RN) Bachelor degree or upon hire commit to actively pursue a degree Three years clinical experience in medical/surgical health care fields psychiatric, and/or obstetrical setting. Currently licensed by the state of Alabama as a RN or, upon hire, agree to actively pursue Alabama license. Upon hire, the incumbent will attest to practice within the scope of their licensure; and each year thereafter will confirm that they do so by signing an attestation agreement. The incumbent will notify management of any issues that impact, changes or threatens this agreement. Effective verbal and written communication skills with providers, subscribers and group representatives. Ability to analyze clinical situations and make informed decisions in an autonomous setting. Specific specialty certifications applicable to the job. The incumbent must notify management immediately of any changes to licensure/certification status.

The incumbent must be an independent thinker and able to work closely via personal, written or oral communication with representatives from the group, the patient and family, marketing, and/or other providers or professionals.

The incumbent has telephone and personal contact with groups, providers and their office representatives, patients and their family members, internal departments involved with medical care, marketing and claims processing, and BCBS Medical Directors and legal staff. This communication may be one-to-one or involve presentation to a large audience. The incumbent must be able to establish effective communication, diffuse situations, or to resolve problems. The incumbent must be able to effectively articulate alternative plans of treatment and benefits to the group, physicians, and the patient and family members.

The incumbent may review cases for medical necessity of services. Cases are submitted for peer clinical review when medical necessity guidelines are not met. Work to resolves problems for subscribers, groups, and providers. The incumbent utilizes analysis and decision-making skills in order to evaluate benefit structures and propose effective plans of treatment. Negotiation and communication skills are necessary for discussing flexible benefits with providers, group representatives, and patients. The incumbent may be responsible for participation in revisions/developments of the Blue Cross and Blue Shield of Alabama medical necessity guidelines. These guidelines are based on existing guidelines, literature review and current trends in health care policy. The incumbent operates in an autonomous environment, where they are responsible for independent thinking and decision-making.

• Activity: Perform utilization reviews to determine medical services provided to members (prospective, concurrent, retrospective, and appeal reviews).
  End Result: To assure that care is medically appropriate.

• Activity: Perform an assessment of a patient's medical status and needs in light of benefit structures and available resources.
  End Result: To propose and/or implement a flexible and quality plan of treatment.

• Activity: Promote acceptance of an alternative plan, including making contractual arrangements to carry out the plan.
  End Result: To coordinate service delivery that meets the needs of the patient and the group.

• Activity: Provide on-going monitoring and review of cases that include revisions to the original plans, problems and goals.
  End Result: To assure that the current plan is effective. To identify barriers to care that may be resolved through intervention.

• Activity: Manage cases that involve catastrophic type illnesses or chronic disease states.
  End Result: To provide quality services across a continuum of care that addresses the needs of each individual served.

• Activity: Educate the patient and all members or the healthcare delivery team about case management, community resources, insurance benefits and cost factors.
  End Result: To ensure that informed decisions can be made by the patient/caregivers.

• Activity: Encourage appropriate use of facilities and services.
  End Result: To improve quality of care and maintain cost effectiveness.

• Activity: Organize and perform on-site medical audits.
  End Result: To ensure that care is appropriate. To determine if services provided under case management are administered as planned.

• Activity: Provide periodic reports to the group on patient progress and benefit utilization.
  End Result: To apprise groups of costs that are attributable to services provided.

• Activity: Respond to telephone or written requests for information from subscribers, providers, and group representatives (within the scope of Privacy Guidelines).
  End Result: To demonstrate our Customer First and Caring Company philosophy.

• Activity: Perform special projects as requested.
  End Result: To promote achievement of divisional goals.

• Activity: Prepare reports for presentations to groups (may be in conjunction with Marketing). Prepares dialogue and support materials for groups, agencies, or providers that focus on education or program components, new programs, claims payment and billing guidelines.
  End Result: To keep groups/Marketing apprised of trends in the healthcare delivery system that impact the group.