RN Case Manager

RN Case Manager needed to support managed care provider for onsite position in Cincinatti, OH.  May be willing to take an RN seeking to transition into Case Management if coming from an acute care setting.  '...Provides concurrent and retrospective utilization reviews, large case management, disability case management and other programs to improve the quality of medical care and control costs.  Works with minimal supervision and is responsible to make an established range of decisions, escalating when necessary, and updating manager on a regular basis. Position Responsibilities:

• Utilizes clinical experience and appropriate clinical criteria and guidelines, along with Plan provisions, in monitoring, evaluating and coordinating both inpatient and outpatient medical care to promote quality outcomes at reasonable costs.
• Performs prospective and concurrent utilization reviews to determine medical necessity for inpatient admission, inpatient continued stay and selected outpatient services to ensure medically appropriate, high quality and cost effective care and for most efficient utilization of third-party services.
• Assists members (associates, retirees and dependents) in navigating the healthcare landscape and optimizing benefit plan utilization by identifying opportunities to promote quality healthcare.
• Monitors potential high-cost claims for early intervention with case management and retrospectively reviews to assure appropriate and cost effectiveness.
• Communicates regularly with members, physicians, physician office staff, pharmacists and hospital utilization personnel.
• Conducts and coordinates case management activities for non-occupational Short-Term Disability, return-to-work and Family Medical Leave Act cases.
• Keeps management and internal physician consultants informed on an ongoing basis of the status of all large case management cases.  Collaborates with management and/or the internal physician consultants on a case-by-case basis.
• Acts as a source of medical information for Benefits Department.
• Keeps up-to-date on current medical trends by regularly reviewing journals and professional publications and attending seminars.
• Documents individual cases for the purposes of cost savings and efficiency analyses and legal record.
• Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality and protection of personal information, including, but not limited to, personal health information and personally identifiable information.
• Provides support as needed for the Company’s occupational nurse and wellness programs.
• Performs other duties as assigned by management...'