Managed Care/HMO Coordinator
Summary
Title:Managed Care/HMO Coordinator
ID:1
Location:Paramount Health Care Company
Department:Clerical
Description

Paramount Health Care Company is a Texas based group of Skilled Nursing Facilities. Our Centers are designed to provide high quality rehabilitation and skilled care for medically complex patients. As part of our continuum of care, we also provide long-term services for geriatric patients with chronic issues.Patients at our centers benefit from a team approach utilizing the experience of our physician, nursing, administration and rehabilitation staff. In order to ensure the best care possible, PHCC only recruits and hires the best and brightest stars in health care.

 

We are currently seeking the expertise of an RN experienced in Managed Care/HMO management. This vital position will provide ongoing support and guidance through comprehensive assessments, planning, implementation and overall evaluation of individual patient needs. In addition, the Managed Care/HMO Coordinator will also enhance the quality of patient management and satisfaction, as well as promote continuity of care and cost effectiveness through the functional integration of case management, utilization review, and discharge planning.

 

 

Essential Job Functions:

 

· Provide SNF case management/utilization review and discharge planning to ensure that Managed Care/HMO residents progress through the continuum of care and are discharged to the least restrictive environment.

· Coordinate the integration of the social service function into patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities.

· Coordinate the SNF activities concerning case management and discharge planning.

· Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff, JCAHO, CMS and other state agencies.

· Adhere to departmental goals, objectives, standards of performance, policies, procedures, and cost effectiveness.

· Ensure patient tests are appropriate, necessary and are carried out within the established timeframe. Ensure results are promptly available and comply with managed care/HMO contracts and facility policies.

· Conducts reviews for appropriate utilization of services from admission through discharge. Evaluate patient satisfaction and quality of care provided.

· Initiates and presents “denial letters” and “authorizations” as appropriate.

· Assesses patient care required throughout continuum of care for diagnosis, procedures, and DRG’s.

· Communicate with SNF at regular intervals throughout stay and develop an effective working relationship. Assist facility with maintaining appropriate cost, case, and desired patient outcomes.

· Complete expanded assessment of patients and family needs at time of admission. Complete psychosocial assessment.

· Refers cases where patients and/or family would benefit from counseling required to complete complex discharge plan to social worker.

· Collaborate with clinical staff in the development and execution of the plan of care, and achievement of goals while adhering to contract guidelines.

· Directs and participates in the development and implementation of patient care policies and protocols in order to provide advice and guidance in handling special cases or patient needs.

 

Qualifications:

 

· Licensed Registered Nurse.

· Minimum of two (2) years of utilization review/case management experience.

· Minimum of one (1) year experience in discharge planning from a hospital is preferred.

· Current professional licensure in nursing professional field of certification.

· Appropriate certification in case management preferred (e.g. Commission for Case Management Certification (CCMC); Association of Rehabilitation Nurses (ARN)).

· Working knowledge of federal, state and county laws governing skilled care facilities.

 

 

 

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