Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com



JOB SUMMARY: CARE MANAGER II - Telephonic Concurrent Review

The Care Manager II - Concurrent Review performs advanced and complicated case review and first level determination approvals for members receiving care in a Skilled Nursing Facility setting determining the appropriateness and medical necessity of continuing inpatient confinement including appropriate level of care, intensity of service, length of stay and place of service. Case reviews and determinations require considerable clinical judgment, independent analysis, critical-thinking skills, detailed knowledge of departmental procedures and clinical guidelines, and interaction with Medical Directors. Reviews may be completed on-site at the facility and/or telephonically, and may be assigned based on geography, facility, provider group, product or other designation as determined appropriate. Performs discharge planning, care coordination, and authorization activities to assure appropriate post-hospital support and care. Acts as liaison between the beneficiary and the network provider and HN to utilize appropriate and cost effective medical resources.



ESSENTIAL DUTIES & RESPONSIBILITIES:

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Conducts advanced and complicated clinical case review for members receiving care in an inpatient setting. Determines the appropriateness and medical necessity of continuing inpatient confinement using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans. Makes first level approval determinations when appropriate. Reviews may be completed on-site at the facility and/or telephonically, and may be assigned based on geography, facility, provider/provider group, product or other designation as determined appropriate.
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Reviews, triages and prioritizes cases to meet required turnaround times. Expedites access to appropriate care for members with urgent or immediate needs using expedited review process.
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Performs research and analyzes complex issues, assess member needs. Acquires appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy.
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Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors.
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Collaborates and communicates with hospitalists, attending physicians and utilization management staff and other health care professionals when appropriate.
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Using professional judgment, independent analysis and critical-thinking skills applies clinical guidelines, policies, benefit plans, etc to determine the appropriate level of care, intensity of service, length of stay and place of service.
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Performs discharge planning, care coordination, and authorization activities to assure appropriate post-hospital support and care. Effectively utilizes community resources and care alternatives.
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Performs all other duties as assigned.

Qualifications


REQUIREMENTS:
Education:
Graduate of an accredited nursing program; Bachelor’s degree preferred

Certification/License:
Valid & active state of Connecticut Registered Nurse license required.
UM/CM certification preferred

Experience:

* Minimum three years acute inpatient clinical experience preferred
* One to three years managed care experience, including discharge planning, Case Management, Utilization Management.
* Health Plan experience preferred
* Visiting Nurse experience preferred


Knowledge, Skills & Abilities:

* Knowledge of NCQA, federal and state regulations/requirements preferred
* Demonstrated ability for assessment, evaluation and interpretation of medical information (chart reviews)
* Prefer a high level of understanding of community resources, treatment options, home health, funding options and special programs
* Strong analytical and problem solving skills
* Excellent verbal and written communications skills
* Excellent case preparation and abstracting skills
* Team player who builds effective working relationships
* Ability to work independently
* Prefered experience using standardized clinical guidelines/criteria required
* Strong organizational skills
* Able to operate PC-based software programs
* Prefer ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.