Manager Aetna Utilization Review Jobs in Rochester, NY

SLH - CPH Main (37.5)

Full time

REQ_241626

Job Title: Nurse Navigator Department: OncologyLocation: Canton - Potsdam HospitalHours Per Week: 37.5 weekly scheduled hoursSchedule: Mon-Fri, 7.5 hour shift SUMMARY: Organizes services across the continuum from pre-registration through discharge from the Center to affect optimal patient outcomes, achieve continuity and quality of care, reduces cost and provide customer satisfaction. Provides assistance to patients and families through evaluation of social, emotional and financial needs and coordinates and facilitates appropriate resources. Communicates with third party payors, follows Health System policies and procedures, and assist with continually improving the quality and effectiveness of case management/patient navigation.

RESPONSIBILITIES:

• Reviews the medical record with referring provider as soon as possible after admission-within the first12 to 24 hours. Applies utilization review criteria to assess and document appropriateness of admission, continuedstay and level of care.

• Interviews patients and/or family members to obtain information about social, emotional, and financial factors which impact health status. Assesses needs for progress along department algorithm of care and continuing care or resource support following discharge.

• Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care or resource support following discharge. Utilize all appropriate medical, social, and financial resources available to support the patient/family and to ensure smooth transition to appropriate levels of care.

• Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care, to initiate referrals.

• Proactively identifies problems with utilization of resources and assures specific tests, consults etc. are done in a timely manner. Feedback is obtained and documented in the patient chart. Forward patient chart to physician for review when problems are identified. Intercedes with appropriate department or attending physician to identify cause. Communicates as needed with Physician Advisor, assures patient is placed on clinical pathway and monitors variances from pathway as appropriate.

• For Spine: Provides counseling, social support, and assistance in crisis situations. Proactively establishes and coordinates patient care conferences if there are care plan batteries, etc. These conferences are to coordinate continuing care plans, monitors plans, and assesses potential need for alterations of plan due to patient’s changing medical condition or social/financial support system.

• Maintains current information on community resources, third party payors, and managed care environment. Knowledgeable of changing rules/regulations, and policies/procedures. Maintains established departmental policies and procedures, objectives, quality management plan, environmental and infection control standards.

• Maintains appropriate and timely documentation through medical record entries, daily logs, computer entries, and monthly statistics. Prepares and maintains required documentation on each patient.

• Completes worksheets, communicates in a timely manner with physicians and coders, provides necessary statistics for data collection, and identifies case mix issues.

• May provide consultation and education to medical and hospital staff of inpatient and outpatient programs regarding role of case management. This may include appropriate management of resources, discharge planning and complex medical/legal issues.

• Assists in development of new services or policies appropriate to patient needs and consistent with strategic plan

• Makes referrals to administrative director, medical director, quality management, risk management, infection control, and hospital departments when potential quality problems are identified. Refers to and consults with clinical social worker on patients with complex psychosocial/financial needs. Develops and maintains professional working relationship with medical staff, hospital staff, and coworkers.

• Maintains strict confidentiality at all times.

• Ensures that quality of patient care is maintained by collecting quality indicators and clinical path variance data, as well as identifying data that indicates potential areas for improvement. Participates actively on clinical pathway, CQL, and clinical process improvement teams. May act as team member, team leader, facilitator, or recorder.

• Provides services, supports or other assistance in a culturally sensitive manner responsive to the patient/families beliefs, attitudes, language and behaviors.

• Provides care appropriate to each patient.

• Develop and maintain strong working relationships with all key internal stakeholders including physicians and center leadership.

• Ensure strict adherence to all established Unity processes, procedures and standards.

• Spine Center Only:

• Throughout the spine center care performs continued stay reviews for medical necessity to re-certify the need for ordered level of care using approved criteria for severity of illness and intensity of service. Discusses with the attending physician the necessity for continued care and requests information regarding the patient’s progress and/or plan for treatment when the medical record lacks this information. Identifies patients that meet discharge and communicates with attending physician. Refers cases that do not meet criteria to Physician Advisor.

• Follows contractual obligations for communications with third party payors. Request certifications for admission and continued stay. Requests information on patient benefits and documents necessary approvals for discharge plans. Interfaces and negotiates with third party payors to ensure payment of services. All insurance related information; including clinical reviews, contacts with third party payors, and authorizations received are entered into the computer database in a timely manner. Follows policy and procedure for Hospital Notices of non-coverage for Medicare patients. Provides retrospective review as needed.

• For Advanced Valvular and Structural Heart Disease

• Performs clinical chart abstraction and submits data to clinical registries for TAVR (Transcatheter Aortic Valve Replacement), TMVR (Transcatheter Mitral Valve Replacement), and LAAO (Left Atrial Appendage Occlusion) procedures.

• Performs procedural authorization duties through chart abstraction, writing authorization request letters and submitting to insurance companies, and tracking insurance company responses to complete follow-up work as needed.

REQUIRED QUALIFICATIONS:

• Graduate of an approved school of nursing, BSN preferred. Nurse Practitioner ideal.

• Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in acute care setting ​

PREFERRED QUALIFICATIONS:

• nurse navigation experience

• experience in oncology

EDUCATION:

AS: Nursing (Required)

LICENSES / CERTIFICATIONS:

BLS - Basic Life Support - American Heart Association (AHA)American Heart Association (AHA), RN - Registered Nurse - NYS Office of ProfessionsNew York State Education Department (NYSED)

PHYSICAL REQUIREMENTS:

Light - Clinical - Light clinical roles involve frequent standing and walking, with occasional lifting of light objects (≤20 lbs.) and routine reaching, grasping, and fine manipulation for tasks such as patient care, laboratory work, or specimen processing. Staff rely on strong visual and auditory acuity to accurately observe specimens, read instrumentation, monitor patients, respond to alarms, and communicate effectively with care teams. Cognitive demands include multitasking, prioritizing clinical and laboratory workflows, and coordinating with interdisciplinary teams. Emotional resilience is necessary due to frequent interruptions, shifting priorities, and the need for precise and compassionate interaction with patients and colleagues. Environmental exposures may include infectious materials, biological specimens, cleaning agents, sharps, chemical reagents, and wet surfaces. PPE use, TB testing, and schedule flexibility are commonly required.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$84,000.00 - $104,000.00

CITY:

Potsdam

POSTAL CODE:

13676

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.

Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials. It’s vision is to lead the evolution of healthcare to enable every member of the communities it serves to enjoy a better, healthier life.