Nurse Clinician Job at Liberty Community Connections
Summary:
- This position will report to the Quality Manager and will be responsible for working in collaboration with the MCO Incident management and Service Coordinator teams, both internal and external to provide oversight on participants Critical Incidents.
Essential Responsibilities:
- Ensures timely review of Consumer Critical Incidents to determine if the appropriate measures are taken in the areas of reporting in accordance with MCO and CMS coverage guideline and State Regulatory requirements.
- Reviews proposed home care, and inpatient / outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.
- Will work in collaboration with the MCO Incident management and Service Coordinator teams, both internal and external to determine medical and social appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Assist Service Coordinator teams with Complex cases, PCSP process where necessary and medication review.
- Will follow the consumer until the Incident has reached conclusion.
- Identify and refer all potential quality issues to the Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
- Other duties as assigned.
Minimum Qualifications:
- Current, unrestricted Pennsylvania RN license or Licensed Clinical Social Worker
- 2+ years of experience in managed care OR 5+ years nursing experience
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