Job Description

Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. This care manager is dedicated to handle the increased volume and to support the overall care management process and the department.

JOB REQUIREMENTS:

Education:

• Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years

Certification/Licensure

• Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts
• Certification in basic life support (BLS)

Experience:

• 2 years Med Surge experience required
• 1 year Utilization review experience required
• 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position required
• InterQual experience preferred

Knowledge and Skills:

• Extensive background and knowledge of current medical/surgical patterns of practice.
• Medical terminology and standard medical abbreviations.
• Managed care concepts, the various health care delivery systems
• Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment.
• Confidentiality issues and the legal and ethical issues pertaining to them.
• ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable.
• Knowledge of benefits and various plan contracts, eligibility issues and requirements.
• Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program
• Excellent interpersonal, verbal and written communication and negotiations skills
• Strong analytical, data management and PC skills

Equal Opportunity Employer/Disabled/Veterans

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