Job Description
Innovative, Dynamic, Fast Pace and Collaborative, these are just some of the words that our employees use to describe us but hey - don’t just take it from us - become a part of BroadPath today and experience our Culture of Constant Connection! At BroadPath we strive to transform the modern workplace by embracing the spirit of revolution coupled with advanced technology to create an experience out of every day.
The Registered Nurse - Medical Management Services will be responsible for providing support and execution of programs and tactics used to influence provider and health plan consumer/beneficiaries’ behaviors, with the goal of achieving the right care in the right place at the right time and the appropriate cost. The Registered Nurse – Medical Management Services is responsible to process health plan medical pre-service requests, provide case management, care coordination, and perform utilization management duties within the appropriate time and in accordance with all federal and state regulations.
Responsibilities
- Manage health plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational outcomes
- Work collaboratively with both internal and external customers in assisting health plan consumer/beneficiaries’ providers with issues related to prior authorization utilization management, and/or case management
- Perform transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination
- Evaluate the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiaries’ outcomes
- Provide ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence-based practices, and all other topics that impact medical management functions
- Ensure quality of service and consistent documentation
Basic Qualifications
*Must Reside in Pacfic Time or Mountain Time Zone
- Active Registered Nurse (R.N.) licensure
- 5+ years of Clinical Experience
- Utilization, Case, or prior Authorization Management ExperienceÂ
- A Bachelor’s Degree or equivalent Experience
Preferred Qualifications
- Certified Case Manager (CCM)
- MCG Certification(s)
- RN-BC Registered Nurse Case Manager
- Certification in Managed Care Nursing (CMCN)
- Basic Life Support (BLS) certificationÂ
