Qualifications

• BA/BS degree and at least three years experience in working care management programs for companies offering employee health benefits, preferred.
• Current RN licensure to practice in the State of California, required.
• 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.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.  
• Home router with wired Ethernet (wireless connections and hotspots are not permitted). 
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)  
• A functioning smoke detector, fire extinguisher, and first aid kit on site.  
• Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 5% of the time.  

Duties And Responsibilities

• Provide education and coaching to members in the Health Management program.
• 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 assist 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 the 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 a positive working relationship with the 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.

• Assist 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.
• Maintain a valid California Registered Nurse’s License.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet. 
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.  
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit). 
• Attend client or off-site meetings as requested.
• Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 5% of the time.
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. 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 communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate