CSHCS Review Nurse
Location: Michigan
Description: Meridian Health Plan is at present recruited CSHCS Review Nurse right now, this job will be placed in Michigan. More details about this job opportunity please read the description below. This position is primarily responsible for identification, review and clinical coordination of processing and receiving approval for children and infants to the CSHCS program. Provides direct outreach to members and provide! rs for education regarding the program and coordination of care with the goal being to enroll the member. Ensures tracking and reporting of key performance measures and collects data for HEDIS reporting.
Responsibilities Include:
Review existing data bases regarding border babies currently hospitalized, historical CSHCS data provided from state enrollees, referrals from Utilization Management, Medical Director, Member Services, Claims, MeridianRx and providers
Initiate the referral and submission process to ensure the successful completion of enrollment in the program
Authorize services and schedule their visits, coordinate their care and assist with providing family members with necessary information regarding the program
Work collaboratively with providers to obtain necessary documentation to support the enrollment process
Work collaboratively with the state to ensure successful enrollment
Review denied case! s to determine potential appeal
Assemble all appeal c! ases to be reviewed by Medical Director
Work closely with Medical Director and Manager on cases to maintain current status
Responsible for accurate record and reporting of CSHCS cases within MCS
Complete authorization process in MCS system for approved authorizations. Receive and process requests for continued stay or additional treatments, as necessary.
Consult with Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval
Create and fax/mail denial letters for members and providers as required and within established timeframes
Ensure that approved requests are faxed back to appropriate hospital, physician or ancillary provider offices
Responsible for conducting reviews of all neonatal admissions including application of clinical criteria, coordinating discharge planning with the facility and the member’s parent/guardian, ensuring all discharge needs are met
Responsible for presenting all prolonged neonatal and pediatric admissions at the Hospital Care Coordination meetings
Develop skills and proficiency with PC based Microsoft Office applications, Windows and other applications particular to Meridian Health Plan
Consistently demonstrate compliance with HIPAA regulations, professional conduct and ethical practice
Perform other duties as assigned
Licensed LPN or Registered Nurse in the state of Michigan is a requirement. One to two years experience in clinical or managed care nursing is required. Experience with office functions including word processing, spreadsheets, mass mailings, etc. is required. Clinical experience in obstetrics and/or pediatrics is preferred. Prior experience with HEDIS/NCQA or CSHCS is a plus. Knowledge of managed care and of Medicaid guidelines. Medical/obstetrical terminology.
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If you were eligible to this job, please email us your resume, wit! h salary requirements and a resume to Meridian Health Plan.
If you interested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Tue, 30 Apr 2013 22:28:17 GMT