Care Manager II - Pre Service Review (Tempe, AZ)

Health Net of Arizona is a subsidiary of Health Net, Inc. (NYSE:HNT). Health Net, Inc. is among the nation's largest publicly traded managed health care companies. Its mission is to help people be healthy, secure and comfortable. The company's HMO, POS, insured PPO and government contracts subsidiaries provide health benefits to approximately 6.5 million individuals in 27 states and the District of Columbia through group, individual, Medicare, Medicaid and TRICARE programs. Health Net's subsidiaries also offer managed health care products related to behavioral health and prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.





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For more information on Health Net, Inc., please visit the company's Web site at www.healthnet.com





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?JOB Summary:

The Care Manager II - Preservice Review performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary services requests.? Reviews include medical appropriateness and medical necessity determination requiring considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures and clinical guidelines. Acts as liaison between the beneficiary and the network provider and HN to utilize appropriate and cost effective medical resources.





Essential Duties and Responsbilities:

Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.? Makes first level approval determinations when appropriate.





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Reviews, triages and prioritizes cases to meet required turnaround times. Expedites access to appropriate care for members with urgent or immediate needs using expedited review process.

Performs research and analyzes complex issues, assesses member needs.? Acquires appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy.? Accurately applies coding guidelines.

Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors.

Using professional judgement, independent analysis and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc to case review.

Summarizes case including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.

Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.

Develops determination recommendations and presents cases to Medical Director for potential denial determinations or when Medical Director input is needed.?

Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.?

Develops and/or reviews appropriate documentation and correspondence reflecting determination.? Assures accuracy, completeness and conformance to standards.

Documents all activities as per unit practice including entry into automated systems.

Recognizes potential quality care concerns and refers as appropriate.

Identifies and refers members who may benefit from disease management or case management and makes appropriate referrals.











Education/experience/minimum requirements:

Education:



Graduate of an accredited nursing program.?

Bachelor's degree preferred.



Certification/License:



Valid state RN license.

UM/CM certification preferred.



Experience:



Minimum two years clinical experience.

Minimum two years managed care experience, including discharge planning, Case Management, Utilization Management, Home Health, transplant or related experience required.

Health Plan experience preferred.



Knowledge, Skills & Abilities:



Strong knowledge of NCQA, federal and state regulations/requirements.

Demonstrated ability for assessment, evaluation and interpretation of medical information.

Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs.

Strong analytical and problem solving skills preferred.

Excellent verbal and written communications skillsAble to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project.?Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations.





Other:





???????? Local travel required.





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Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.