Clinical Case Manager II - Concurrent Review

Mercy CarePlus, a leading healthcare company serving Medicaid members, is expanding the Concurrent Review unit.  In response to increased membership, we are searching for an experienced Registered Nurse to join our Medical Management Team.

 

 Position Description:

Applies InterQual criteria to perform concurrent review, retrospective review and discharge planning to assure that eligible members are treated in the most appropriate and cost effective setting.

 

Responsibilities of this position include:Telephonic review of the clinical status of hospitalized patients by communicating with hospital case managers, discharge planners, physicians, patients and familiesReview case records,  apply criteria, analyze data, evaluate patients’ medical status to determine needs and problem solve to provide all needed servicesCollaborate with Chief Medical Officer in a timely manner to resolve cases requiring review, initiate discharge planning and refer members to case management as neededResponsible for accurate and timely documentation of medical information and notification to members and providers of authorized or denied servicesAble to meet administrative requirements, including time management and quality standards with a minimum of supervisionSupport quality improvement activities by identifying quality issues, monitoring quality of care, conducting data analysis, risk categorization of members

 

Qualifications:Registered Nurse with current Missouri license requiredTwo years managed care experience preferredGreater than three (3) years Medical Surgical or OB nursing experienceStrong decision making skills requiredWell developed technical and clinical skills requiredWorking knowledge of Word, Excel preferred