Care Management Review Nurse
Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.
WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!
To learn more watch our Company Video!
Job Description Summary
This is a high level clinical position responsible for administering and operating Western Growers Assurance Trust’s (WGAT) and Pinnacle Claims Management Inc.’s (PCMI) third party and direct care management/utilization, disease management and case management objectives and initiatives. This position reports to the Nurse Supervisor and requires a high level of clinical judgment and independent decision making skills.
- BA/BS degree and at least three years’ experience in working care management programs for companies offering employee health benefits.
- Current RN licensure to practice in the State of California.
- Currently licensed as Certified Case Manager (CCM) preferred.
- Comprehensive understanding of generally accepted medical practices, state and ERISA mandated benefits, plan language, and contracts.
- Good understanding of health benefits claims processing, knowledge and understanding of current procedural terminology (CPT) and international classification of diseases (ICD) 9/10 codes preferred.
- Ability to develop and present health educational sessions around health, nutrition and other care management topics is required.
- Proficient in end-user software programs e.g. word-processing, calendaring, spreadsheet, and electronic health record software required.
- Knowledge of McKesson end user software and integration of Interqual medical guidelines preferred.
- Excellent oral and written communication skills in English and Spanish preferred.
Duties And Responsibilities
- Review and approve referral requests for medical and other specialty services, diagnostic services, and other ancillary services using established medical criteria (per protocol).
- Develop and implement procedures for determining medical necessity, physician review, and a grievance procedure for both members and providers.
- Ensure regulatory compliance and maintain routine monitoring and oversight of the organization’s case management programs.
- Provide clinical guidance and oversight of the department’s care management activities.
- Serve as subject matter expert on all care management questions and assists underwriting and claims departments with clinical expertise.
- Act as a clinical subject matter expert and a point of contact on matters of clinical content.
- Provide clinical expertise to Product Development in the development of applications and tools.
- Act as a client facing clinical subject matter expert and a clinical point of contact.
- Perform pre-certification process by obtaining, organizing, and synthesizing clinical, benefit, and network information.
- Obtain and maintain clinical records from providers and facilities
- Perform claims medical necessity review.
- Maintain positive working relationship with Provider Maintenance (PM) Department and advise PM of issues with contracting, network, and rosters.
- Determine when physician advisor involvement is appropriate on a case by case basis. Follow-up with the results of reviews sent to physician advisors.
- Provide assistance to the claims examiners or customer service staff as needed when updating the system notes regarding managed cases.
- Interact (electronically & telephonically) with employees of other carriers such as Blue Cross and other networks to resolve pricing and contract issues.
- Provide prognosis reports for the Underwriting Department, as needed.
- Monitor large dollar case management clients to ensure effective cost savings while assuring the client receives quality health care.
- Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
- All other duties as assigned.
Physical Demands/Work Environment
The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand, walk and sit. The employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.