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The RN Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination.
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These responsibilities may include utilization review, pharmacy oversight and care coordination. Five (5) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required.
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Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management, and preventive care services.
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Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities. Knowledge of utilization management, quality improvement, discharge planning, and cost management.
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Communicates effectively with claims adjuster, client, vendor, supervisor and other parties as needed to coordinate appropriate medical care and return to work. PRIMARY PURPOSE: To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer.
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As a physician, you will work with the actuarial, technology, medical care coordination, and medical quality management teams. Experience in managed care and utilization management.
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