Collaborates with member, family, healthcare providers and other members of the healthcare team to coordinate services and develop a plan of care. Assesses, plans, implements, monitors and evaluates options and services for members admitted to acute and subacute facilities, receiving home health services or those independent at home.
Performs onsite assessment and telephonic review of admitted Members to determine appropriate management through facts documented in the medical record or recognized from contact with the Member or facility staff.
Actively involve with facility staff to insure adequate, appropriate and timely discharge planning.
Works with designated transplant vendor to actively manage Members who are identified as requiring transplant.
Coordinates approval for services within the transplant vendors and the Health Plan network of facilities and completes documentation in the Medical Management computer systems to assure appropriate application of benefits.
Performs prior authorization for items on the prior authorization list; performs precertification through on-site, electronic or telephonic concurrent assessment or retrospective review of Members admitted to acute and sub-acute inpatient facilities, as well as members in an at home setting to assure appropriate utilization through facts documented in the medical record or recognized from contact with the Member, Member's family, or facility staff.
Actively engages with facility staff to assure adequate, appropriate and timely discharge planning.
Interacts with Members, Members' families and Authorized Representatives as needed to explain benefits, assist with discharge planning, notify of denial of coverage with explanation of Peer to Peer and Appeal Rights.
Complies with all regulatory guidelines related to utilization management processes and assures that all regulatory time frames for decision-making are met.
Provides benefit focused case management, coordinating care in accordance with the member's benefit document to members authorized for services outside the health plan network.
Provides assistance to eligible members seeking continuity and coordination of care when all conditions of policy are met for Provider or Practitioner terminations for reasons other than cause and for new members currently undergoing treatment by a Practitioner or Provider who is not participating with the Health Plan.
Provides On-Call coverage, on a rotating basis as assigned, for services during non-business hours.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
*Hours: Monday - Friday, 8am -4:30pm or 8:30am - 5pm.
*This position will be required to manage clinical calls in the Medical Management phone queue
*Geisinger offers comprehensive suite of healthcare benefits all starting day one of employment! This includes medical, prescription drug, vision and dental coverage. We also offer up to $5,000 tuition reimbursement and 5% contribution to your retirement plan.
Graduate from Specialty Training Program-Nursing (Required)
Minimum of 5 years-Nursing (Required)
Certification(s) and License(s)
Licensed Practical Nurse - Default Issuing Body
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.