RN-Case Management Analyst

Case Management Analyst
Location: Nashville, TN
Hours: M-F 8-4:30
Start: ASAP

Position Summary:
Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources.
Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services.
May also manage appeals for services denied.
May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts.
May be responsible for day-to-day operations of a single or multiple IPA/IPOD and staff, and may serve as liaison with the local health plan to ensure continuity for IPA/IPOD members.

Essential Duties and Responsibilities:
-Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
-Evaluates and authorizes the medical necessity of some inpatient and outpatient services.
-Notifies provider of recommended changes in level of care.
-Evaluates cases for quality of care and documents quality issues.
Issues letter to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.

Knowledge, Skills, Abilities Required:
-Excellent interpersonal and communications skills with clinical staff, management, and all departments involved in the care of our customers.
-Ability to meet deadlines, make decisions on what needs to be done and manage multiple priorities, and effectively adapt and respond to complex, fast-paced team environment and to promote team concepts

Qualifications:
Current license as an RN in the state of Tennessee Required.
At least one year clinical, utilization management and/or case management experience.
Working knowledge of the insurance industry and the overall claims process a plus.