Clinical Navigator (Remote)

PURPOSE

The Clinical Navigator (RN) conducts concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care, and case management to engage members/enrollees, their families and other support systems in discharge planning.

Essential Functions

• Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services.
• Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
• Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care.
• Applies sound clinical knowledge and judgment throughout the review process.
• Follows member benefit contracts to assist with benefit determination.
• Makes referrals to other care management programs as appropriate for chronic, long-term care coordination.
• Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience.

Qualifications

• Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
• Licenses/Certifications: Upon Hire Required RN - Registered Nurse - State Licensure And/or Compact State Licensure: RN - Registered Nurse in MD, VA or Washington, DC.
• Experience: 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review.
• Preferred Qualifications: Knowledge and experience with MCG, Experience working with Commercial and Federal Employee Program employee group member and Medicare/Medicaid enrollees and benefits contracts, CCM certification, MCG certification, Knowledge, Skills And Abilities (KSAs): Strong interpersonal skills and the ability to engage in a member facing environment telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs, Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed, Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point, Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis, Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations, Knowledge of available community resources and programs, Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).