
Arizona Priority Care
JOB DUTIES
- Participates in calling Medicare Advantage, (MA) members for the Telephonic Care Management Program and the COVID19 Program.
- Performs ED follow-up calls.
- Facilitates member/family/caregiver education through referrals to Complex Case Management, (CCM), Palliative Care, (PC) and Telephonic Care Management, and Hospice as appropriate.
- Identifies any psychosocial needs of the member and facilitates referrals to social work and/or behavioral health, as necessary.
- Documents relevant changes in qHMO of member’s condition or status, as they occur.
- Acts as a backup to the concurrent review RN for performing the initial hospital admission review, and collaborates with AZPC Medical Directors, for medical necessity determination for in-network hospitalized members.
- Performs re-reviews on all status changes, and collaborates with the Medical Director for appropriate status determination.
- Writes appropriate rationales on all reviews that do not meet status requested.
- Performs re-reviews on all disputed Provider Dispute Resolutions, (PDR’s) and collaborates with the Medical Director for medical necessity determinations.
- Reviews Acute Rehab and Long Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.
- Assists the Skilled Nursing Facility, (SNF RN) as needed to ensure timely and safe discharges..
- Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
- Identifies and submits Potential Quality Incidents, (PQI)s to the Medical Director.
- Equally shares in after-hours, week-end rotation and Holiday coverage for Care Coordination Department.
- Strong teamwork philosophy and willingness to accept change proactively.
- Other duties as assigned.
EUCATION, TRAINING & EXPERIENCE
- Current unrestricted AZ Nursing license – BSN RN preferred.
- Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
- 3.5 years acute care or care management experience. Medical, ER, Tele, ICU or other relevant clinical role requiring quick critical thinking experience preferred.
- Must have the ability to present clinical information both accurately and confidently.
- Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
- Ability to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
- Ability to work both independently and as part of a team, with minimal supervision.
- Excellent customer service and communication skills, both oral and written.
- Ability to navigate numerous Electronic Health Records systems.
To apply for this job email your details to team.player@azprioritycare.com