Nurse Navigator

6 days ago

Arlington Heights, Illinois, United States The Health Plan Full time
Job Title: Nurse Navigator

Join The Health Plan as a Nurse Navigator and play a vital role in ensuring our members receive the best possible care. As a key member of our team, you will be responsible for conducting systematic admission, concurrent, and retrospective hospital reviews to assess the severity of illness and length of stay. Your expertise will be essential in implementing discharge planning and managing inpatient authorizations, ensuring that our members receive the necessary care and support.

Responsibilities:
  • Conduct telephonic and/or on-site admission, concurrent, or retrospective reviews of all inpatient admissions and observation stays.
  • Enter data timely and update principle/secondary diagnoses and procedures, medical histories, and consults.
  • Investigate missed admissions, obtaining pertinent details, and refer to the Medical Director as appropriate, with completion of documentation and follow-up.
  • Determine the appropriateness of admission and continued stay using established clinical criteria.
  • Refer admissions/continued stays with questionable medical necessity to the Medical Director, with completion of documentation and follow-up.
  • Coordinate care in collaboration with the member, family, healthcare team members, hospital utilization review, social workers, and other resources to intervene proactively and identify needed medical services, utilization, and discharge issues.
  • Identify members requiring discharge planning and facilitate interventions to coordinate care and services.
  • Identify members that may need chronic disease navigation, complex case navigation, social service intervention, and refer appropriately.
  • Act as a liaison between the member, provider, and The Health Plan.
  • Collaborate and share knowledge and expertise with peers, supervisors, and other staff.
  • Serve as assigned on departmental or company committees and attend departmental or work-group meetings as scheduled.
  • Promote communication, both internally and externally, to enhance the effectiveness of medical management services.
  • Identify opportunities for improvement in systems, processes, functions, programs, procedures, and make recommendations to the appropriate management staff.
  • Prioritize assignments appropriately and maintain flexibility as new priorities arise.
  • Identify potential quality issues, variances, hospital-acquired conditions, and never events and refer to the QI Department.
  • Identify requests for new technology and communicate that data to the Medical Policy Director.
  • Take after-hours and weekend call on rotation as assigned (volunteer only).
  • Strive to improve quality in all areas of responsibility and cooperate with all departments to improve quality through The Health Plan.
  • Determine the appropriateness of pre-authorizations using established clinical criteria and/or guidelines.
  • Review and evaluate relevant information, including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits, and member eligibility, in making decisions and recommendations that are consistent with sound medical and managed care practice.
  • Facilitate access to care, provide liaison services, advocate for, and educate members as needed.
  • Educate providers when indicated.
  • Promote communication, both internally and externally, to enhance the effectiveness of clinical services.
  • Develop and implement personalized care plans and use specific assessment tools and revise these accordingly.
  • Reinforce appropriate self-care teaching and monitoring and provide up-to-date medical or behavioral health care information to help facilitate the member's understanding of their options.
  • Help members actively and knowledgeably participate with their provider in their own healthcare decision-making.
  • Identify and report potential high-cost cases to the reinsurance or stop-loss carrier through hospital review, referral requests, care or complex case navigation, or claims cost reports.
  • Utilize clinical skills to assess, plan, implement, coordinate, monitor, and evaluate each individual case, including those members identified by, but not limited to, Pharmacy Reporting, Depression Screening, Health Risk Assessments, and screeners, readmission assessments, and iPro risk data and reporting.
  • Provide telephonic guidance and support to members, physicians, and other healthcare providers to facilitate the best options to meet an individual's healthcare needs.
  • Contact and engage member participation in the appropriate chronic disease navigation program.
  • Assess and stratify on the appropriate intervention level and assess and monitor member status through scheduled outbound calls and inbound calls.
  • Utilize critical thinking skills to manage and evaluate member status and current treatment regime against evidence-based guidelines.
  • Complete outreach in a timely and effective manner according to protocols and make adjustments to frequency and types of contacts to meet program goals.
  • Facilitate proactive interventions to include the application of appropriate therapies and systematic surveillance of appropriateness of medication, education, and counseling about daily self-management and symptom management.
  • Perform screenings and assessments of potential chronic disease navigation cases.
  • Demonstrate a working knowledge and adherence to contractual guidelines and policies of The Health Plan.
  • Assist in the development, implementation, and coordination of new and ongoing chronic disease navigation programs and projects.
  • Achieve optimal clinical and quality outcomes by effectively managing care and resources.
  • Participate in quality improvement activities to achieve program outcomes.

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