Incident Management Consultant III, Registered Nurse Review

Job Summary: In addition to the responsibilities listed below, this position also coordinates the review, evaluation of potential quality outcomes, and resolution of complaints, grievances, and appeals by leveraging medical knowledge and maintaining compliance to medical protocols, referral methods, claims submission processes, and regulatory guidelines; examining available medical records and treatment summaries to conduct a clinical review of a standard and/or non-standard coverage request based on medical necessity criteria, individual coverage contracts, specific health plans, coding rules, and/or other regulatory standards; documenting the review process including decisions for determination of coverage, questions for the physician, and/or potential denials to the physician review staff;implementing new criteria or changes in existing criteria; and collaborating with stakeholders regarding medical necessity criteria, contract terms, interpretation of contract language, and notification of determination outcomes.
Essential Responsibilities:

• Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
• Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
• Performs member, customer, or employee incident case management by: monitoring and analyzing the case tracking database to identify moderately complex, specialty, or flagged cases that require resolution as well as reporting trends to management; processing moderately complex and specialty/flagged incident cases; and ensuring compliance of own work with internal and external rules in the performance of case management activities with some review necessary.
• Performs member or employee incident case research by: investigating claims, authorizations, member contracts, and/or customer service interactions across members and customers to make determinations for moderately complex and specialty or flagged incident cases.
• Resolves member or employee incident cases by: making decisions regarding moderately complex or specialty/flagged incident cases through interacting with business leaders and other stakeholders; and resolving moderately complex or specialty/flagged cases and implementing case decisions.
• Performs customer service by: providing accurate information to members, customers, employees, or other stakeholders related to the status and outcomes of moderately complex or specialty/flagged cases in an appropriate timeframe; and communicating with and diffusing frustrated members, customers, or other stakeholders in moderately complex or specialty/flagged cases involving highly charged, sometimes emotional situations.
• Performs case documentation by: maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for moderately complex or specialty/flagged cases; and documenting moderately complex or specialty/flagged cases in accordance with all internal and external requirements.

Minimum Qualifications:

• Minimum three (3) years of experience in an inpatient setting, clinic, and/or skilled nursing department or a directly health-related field.
• Minimum one (1) year of experience in customer service or a directly related field.
• Bachelors degree in Business Administration, Economics, Health Care Administration, Health Services, Communications, or related field AND minimum two (2) years of experience in health care, health insurance, sales and marketing, or a directly related field OR Minimum five (5) years of experience in health care, health insurance, sales and marketing, or a directly related field.

• Basic Life Support required at hire
  

• Registered Nurse License (Nevada) required at hire