CSHCS Review Nurse
Location: Michigan
Description: Meridian Health Plan is at the momment seeking for CSHCS Review Nurse right now, this position will be placed in Michigan. For detail informations about this position 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 outr! each to members and providers 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 cases to determine potential appeal
Assemble all appeal cases 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 al! l 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.
- .
If you were eligible to this position, ! please email us your resume, with salary requirements and a resume to M! eridian Health Plan.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Thu, 29 Aug 2013 08:47:37 GMT