Triage/Intake Nurse

 

The Care Management/Health Services Triage/Intake Nurse is responsible for assisting in the ongoing management and interventions of the Arcadian?s Care Management Program, with direct responsibility for managing, addressing, and re-directing incoming referral authorization requests to Arcadian Health Plan (AHP) through AHP-online system (AOS) and through other forms of information requests.

 

Qualifications:

 

Education: 

? Bachelor?s Degree in health care related field is preferred.

? Valid and active California Registered Nurse license.

 

 

Experience:

? Minimum of 3-5 years experience in Medicare managed care.

? Participation or experience in CMS audits.

? Proficiency in computer and software programs (e.g.; Microsoft

? Word, Excel), and the Internet

? Knowledgeable of CMS/Medicare benefits related to beneficiary coverage.

 

 

Core Competencies:

 

? Effective verbal and written communication style, with proven ability to positively influence behavior.

? Conflict resolution skills, and change management skills.

? Independent thinker, logical.

? Self directed with the ability to work independently.

? Excellent administrative and organizational skills.

? Strong computer and data entry skills, ability to type at least 50 wpm.

? Current Drivers License for some daytime travel when necessary.

? Ability to multi-task and work closely with all those that are involved in AHP service delivery, including Medical Director(s), providers of care, provider relations (network management), compliance officer(s), member services staff, care management staff, and AHP members.

 

Job Duties and Responsibilities:

 

? Responsible for insuring that health plan meets CMS delegation requirements for both UM and Appeals/Grievances turn around timelines (TATs), including but not limited to:

? Timely processing of utilization requests for pre-service, concurrent, and retro referral requests.

? Timely processing of appeals and grievances for expedited, routine/ standard, and post-service.

? Participates in different aspects of CMS Audit/Mock audits for the Health Services Area, including but not limited to:

? Pre-audits/Mock Audits

? Preparation for actual audit

? Audit Tools.

? Responsible for working with the medical director regarding all aspects of AHP care management services to its members.

? Participates in daily/weekly/monthly rounds as set by Care Management protocols.

? Shares feedback and process improvement ((PI) information with respective stakeholders.

? Manages daily work queues by order of priority, and provides documentation/guidance in relation to necessary key information that should be attached to referral requests.

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Physical Requirements of the Position:

 

? Sitting:  The essential functions of this job are performed while seated at a desk or work station for at least 75% of scheduled work hours.

? Standing and walking: The essential functions of this job require the ability to move from one location to another either by walking, driving, or airplane travel.

? Hearing:  Must be able to receive and send detailed information through oral communication and clearly understand people speaking in her/his presence and over the telephone.

? Speaking:  The essential functions of this position require speaking and communicating English in a clearly understood voice at all times during scheduled work hours.

? Fingering and repetitive motions:  Functions of this position require a significant amount of movements of the wrists, hand, fingers in the use of office equipment such as phones and computer keyboards.

? Vision:  The essential functions of this position require the ability to clearly see detailed information via written manuscript and or computer.

? Lifting:  A function of this position requires the ability to lift at least twenty-five pounds on an occasional basis.

? Travel: Access to a car and ability to drive to provider offices, ability to travel by plane or comparable transportation.

 Salary:  Starting salary is based on qualifications and experience. In addition, Arcadian does not permit or provide compensation or anything of value to its employees or agents, condition employment of its employee or agent evaluations, and set its employee or agent performance standards, based on the volume of adverse determinations, reductions or limitations on lengths of stay, benefits, or services.