Resp & Qualifications

PURPOSE: 
The NICU/Peds Clinical Navigator (RN) manages the timely and smooth transition from inpatient care to home or other levels of care utilizing experience and skills in both case management and utilization management. This includes proficiency in established guidelines to determine medical necessity, appropriate level of care, and engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison both onsite at local hospitals and telephonically; occasional weekend work may be required with the hospital care team including case managers, social workers and discharge planners to ensure CareFirst members/enrollees receive the appropriate level of care and partner to address any potential barriers to discharge. We are looking for an experienced Registered Nurse with NICU and pediatric experience living within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Bilingual - fluent in Spanish a big plus!

ESSENTIAL FUNCTIONS:

• Utilize clinical expertise and critical thinking skills to analyze available clinical information, electronic medical records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages onsite and/or telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address member's medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
• Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination.
• Makes appropriate referrals to other Care Management programs as appropriate for chronic, long term care coordination.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure. RN - Registered Nurse in MD, VA or Washington, DC Upon Hire Required.

Experience: 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review.

Preferred Qualifications:

• Knowledge and experience with Milliman Care Guidelines.
• Experience working with both employer group membership and Medicare/Medicaid enrollees and benefits contracts.
• CCM certification.

Knowledge, Skills and Abilities (KSAs)

• Strong interpersonal skills and the ability to engage in a member facing environment (in-person or telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care deliver partners to meeting member/enrollee needs. 
• Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point.
• Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis. 
• Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations.
• Knowledge of available community resources and programs.
• Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  
  

Salary Range: $71,496 - $141,999

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