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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

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Position:  PreCert/Concurrent Certification RN
Reports To: 
Division:  BANA Medical Affairs (2111)
Company:  ABCBS
Location:  Label
Job Code:  396216
Min Salary:   50000
Date Posted:  10/4/2013

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Position Specific Requirements: No position specific requirements.


Job Summary
This position is accountable for reviewing in-patient admissions, concurrent facility stays and op procedures for Walmart employees prior to and ongoing for the purpose of resolving medical, contractual, or technical issues/questions by applying evidence based criteria and corporate policies.   The incumbent serves as consultant to Level I LPN’s to review and/or collaborate when review determination cannot be met based on initial clinical.

Nature & Scope
ENVIRONMENT
In order to enable the company to continue to meet the needs of its customers in a changing and competitive marketplace, the Certification Nurse is required to adapt to constantly updated medical criteria and enterprise procedures, policies, and contracts.   The organizational environment is one of teamwork and supportive relationships with team members.

WORK FLOW
This position receives telephone calls and faxed clinical to be reviewed directly by the pre-certification nurse for approval/disapproval.   This position receives written and oral inquiries from Customer Service, providers, and members.   The position collaborates and works very close with Customer Service and Care Management.

GUIDANCE
The incumbent must be self-directed and make active attempts to influence events to achieve goals.  He/She must have the ability to prioritize and make sound judgments, utilizing evidence based criteria and computer systems.

CHALLENGES
The challenges of this position are centered on the incumbent’s ability to properly define the direction in which to proceed with all areas related to the pre-certification process, including review of clinical documentation and comparing to guide lines to ensure the stay/procedure meets established criteria.   The incumbent is also challenged with planning and organizing projects assigned directly to this position for completion within established timeframes.

INTERFACES
The incumbent’s contacts within the Enterprise include:  Professional and clerical staff, Customer Service, Care Management, Director of Medical Management, QPM, and the Medical Director for the coordination, processing and completion of work assignments and projects.  The incumbent works with the Medical Director for implementation of and clarification of Corporate Medical Policy and its application to evidence based criteria, review of request for admissions, length of stay and concurrent length of stay.

AUTHORITY
The incumbent has the authority to make decisions regarding pre-certification and concurrent review using evidence based criteria guidelines established for the review of inpatient stays and op services.   This position requires that these decisions be based on sound judgment and complete understanding of the relationship of contractual limitations and evidenced based standard/non-standard care.

This position requires excellent oral and written skills; the ability to make sound judgments and decisions based on facts and guidelines, and the ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency.  The incumbent demonstrates and ability to train and educate others on the current pre-certification processes.

Minimum Job Requirements
 
  • 1. Registered nurse license, state of Arkansas, URAC Requirements.
  • 2. RN experience in nursing to include a broad background in various facets of nursing    OR    experience as an RN to include a broad background in various facets of nursing AND experience as an LPN as stated above.
  • Experience with a health insurance organization in the area of medical review a plus.
  • 3. Utilization management experience or background in medical economics preferred.
  • 4. Surgical or critical care nursing background preferred.
  • 5. Typing or data entry skills.
  • 6. CPHM Certification must be achieved within two years of employment.

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Conduct review for all inpatient/outpatient hospital, physician, and supplier requests for approval for Walmart business.
2. Attain performance standards as established in the business plan for the division.
3. Assist in the research and development of special projects involving specific providers, contractual issues, medical necessity or medical policy issues, and work flow issues.
4. Remains current with ongoing changes in billing and medical practice by use of evidence based guidelines and medical policy.
5. Participate in the development and updating of desk procedures and guidelines.
6. Maintain and update knowledge of new medical and surgical procedures and products, new drugs, and general trends in health care delivery.
7. Consult with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all product lines, Corporate Medical Director, Staff Attorneys, and others within the Enterprise.
8. Initiate correspondence to physician, suppliers and hospitals requesting additional information on questionable inpatient admissions and out-patient procedures.
9. Assist the Legal Division with defense of cases involving review decisions and guidelines, including participating in courtroom activity as needed.
10. Assist in the ongoing development and updating of guidelines as new ones are identified.
11. Works collaboratively with other teams within the division
12. Assist in Insurance Department and legal appeals to answer provider or policy holder concerns.
13. Participates in on-going evaluation of himself/herself and of the nursing team.   Assists in the development of plans for process improvement.
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