At Vantage Health Plan, Inc., we specialize in taking care of people: our members, our patients, and our employees. We offer competitive salaries and great benefits! Benefits include: Health, Dental, Life, Accidental Death and Dismemberment, Long Term Disability, Paid Time Off, and 401(k).
Vantage is currently looking for a Medical Management Inpatient RN to work at from 8:00AM – 5:00PM, Monday through Friday. This is a potential work from home opportunity if candidate lives in Louisiana, Arkansas, or Mississippi.
The Medical Management Inpatient RN is directly involved within the Medical Management (Utilization Review) program of Vantage Health Plan and assures the delivery of medically necessary, quality patient care through appropriate utilization of resources in a cost effective and timely manner. The Medical Management IP Nurse is an intricate part of this program by utilizing Vantage’s authorization system to review and approve services based upon Standardized Criteria, Health Plan Medical Policy and Clinical Guidelines and the local delivery systems. Each request for service is authorized in accordance with the member’s health plan benefits and mandates from regulatory agencies.
Essential Duties & Responsibilities:
• Clinical data collection from providers on every acute Observation, Inpatient, SNF, LTAC and Rehab admission request
• Adheres to the timeline criteria set forth per Medicare and NCQA standards
• Management of every Inpatient Coverage Determination
• Clinical update reviews on acute inpatient hospital cases and SNF/LTAC/Rehab cases
• Additional clinical received from the facility is reviewed by the nurse. Any case that does not meet InterQual admission criteria or a VHP admission policy is then submitted to the medical directors for review and approval/denial of specific case
• Follow up on OBS v IP cases. This requires either additional clinical for secondary reviews or an Inpatient denial
• Follow up on overdue clinical updates
• Create appropriate denial letters for members to be able to understand the denial reason with detailed explanation in laymen terminology
• Monitors the member’s Benefit Period with relation to the Benefit Periods timeframe, how many Acute, LTAC and SNF days have been utilized per benefit period.
• Notifies the member or the member’s appointed personal representative when the member is approaching the exhaustion of available bed days left to use and makes recommendations in writing for obtaining additional medical coverage assistance
• Communication with various case management departments and facilities on high acuity patients. This may include direction from the IP nurse regarding post-acute placement, in network versus OON providers, authorization requirements for different levels of care, and other general questions regarding the needs of these members
• Completion of IP admission cases in a timely manner which involves the coding of procedures performed, diagnoses codes, and estimating a DRG to those cases if applicable per facility and contract
• Generates approval and/or denial letters for the member and requesting provider in a timely manner per MC and NCQA standards
• Work the Daily ques from the claims and accounting department
• Meeting the deadline set forth by VHP’s accounting department by confirming all the “previous” month’s IP cases are completed to include the final days, appropriate diagnosis codes entered per case as well as the cases being assigned a DRG (Enters authorizations for specific member and/or facility Inpatient appeal cases
• Manages all SNF Appeal cases that involves providing in writing a detailed explanation for continued services to VHP’s 3rd party QIO source KEPRO
• Produces Clinical Case Reviews from a Medicare Advantage and a Commercial/Exchange on a monthly basis for the URQM meeting held monthly
• Assisting the Administrative Assistant with DRG letters
• Setting up Peer to Peer calls between the facilities and the Vantage Medical directors
• Assignment of extracurricular duties such as uploading high dollar Reinsurance cases, transplant cases, additional reviews of denial letters prior to going out to a member, managing private member authorizations, monitoring the communications between the different software programs utilized within VHP and training of new hires