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Is prepared to conduct PPS meetings maintaining MDS assessments per Medicare schedule and maintain PPS board for monitoring of Medicare days and RUGs utilization in the absence of the Care Management Coordinator.
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Is prepared to conduct PPS meetings maintaining MDS assessments per Medicare schedule and maintains PPS board for monitoring of Medicare days and RUGs utilization in the absence of the Care Management Coordinator.
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Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member's case assignment.
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The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. The Utilization Management Nurse III is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services.
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Position Summary: This position requires knowledge of Resource Management, under and over utilization, discharge planning, Medicare and government payer regulations, quality control and process improvement activities as related to Utilization Management.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post acute services such as inpatient rehabilitation.
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Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
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Accountable for the overall integration, management and implementation of the Medicare Risk Adjustment Program across HCSC (i.e. network management, customer service, clinical services, information technology, and finance departments.
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The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.
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With Utilization Management, Support Services, ED, and other hospital departments, manages bed control by ensuring appropriate policies and procedures, effective communication channels, rapid response to EPRP for bed, and timely dispute resolution.
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Provides oversight of the utilization review process for medical necessity determinations for skilled nursing facilities using Recovery Care Guidelines-MCG and Home Health using the Medicare Benefit Policy Manual.
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Knowledge of medical terminology, healthcare finances, alternative care options, utilization management, health plan criteria, established criteria such as MCG formerly known as Milliman Care Guidelines and its applications required.
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Research, identify, & implement new approaches and methods to facilitate utilization and cost management, auditing of claims, and benchmarks for tracking project progress. Data and Informatics Responsibilities: Associate Director, Managed Care Informatics and Data oversees and coordinates the extraction, aggregation, and quality assurance of data from multiple sources in support of performing managed care plan and Ryan White reporting, operational reporting and quantitative analyses of utilization, eligibility, quality, and claims data.
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The Assistant General Counsel I supports and reports to the Chief Legal Officer and provides legal advice on a wide variety of matters related to Community's Medicare, Medicaid and Marketplace programs and operations including contracting, quality, utilization management, network management, privacy and security, litigation, fraud, waste and abuse, and contractual and regulatory compliance.
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The Care Management Nurse, MDS Nurse works the RAI process and conducts assessments and care plan coordination for those residents assigned. Ciena Healthcare is Michigans largest provider of skilled nursing and rehabilitation care services.
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