Medical Management Nurse Education And Development Coordinator / FULL TIME - REMOTE*

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• COMPETENCY

• Complies with laws and regulations that govern the medical management services.
• Adheres to IMMS Policies and Procedures
• Follows Policies and Procedures for Personal Health Management and utilization management
• Understands of IMMS holistic approach to medical management
• Understands the client’s (customer’s) perspective and needs
• Adheres to of the CMSA Standards of Practice
• Advocates for participant to obtain quality health care
• Identifies liability issues associated with the performance of medical management
• Adheres to CMSA Standards of Practice and Professional Code of Ethics
• Understands legislative acts, such as the ADA
• Understands purpose of URAC knows how to access the standards
• Uses Milliman Care Guidelines
• Competency with InforMeds’ Web-based products as they relate to Medical Management, including referrals, Clinical Claims Chart, EBM, Risk Stratification, etc.
• Knows how to access and uses the Summary Plan Descriptions (SPD)
• Functions independently
• Demonstrates flexibility and willingness to change
• Provides and documents proactive medical management interventions
• Assesses and documents clinical and behavioral outcomes
• Identifies and documents financial outcomes according to InforMed’s standards
• Consults with IMMS Medical Director on issues of concern about participant treatment plans
• Refers all participants who have a patient severity of “high” to Personal Health Management
• Triggers participants for review
• Reviews participants as triggered
• Documents thoroughly, that is completes each component of documentation, such as treatment plan, diagnoses, cost savings
• Documents objectively, succinctly, and in accordance with IMMS guidelines
• Bills for activities appropriately
• Enters billable time into “Activities” that accurately reflects all participant specific activities
• Enters billable time into “Analytics” for non patient specific activities
• Under direction of TL, manages accounts using the 4-Pronged approach
• Expected number of billable hours are met
• Completes MMOTS protocols as appropriate
• Uses MMOTS tools
• Offers assistance to team participants when needed and/or as time allows
• Requests assistance from team participants when needed
• Attends staff meetings
• Attends staff training
• Obtains at least 8 CEUs per year and documents CEUs on educational log
• Applies for certification if eligible
• Arranges coverage for accounts when planning PTO

• PERSONAL HEALTH MANAGEMENT

• Reviews daily calendar for new episodes and tasks due
• Prioritizes tasks listed on calendar
• Adheres to IMMS indicators
• Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the participant and the physician’s assessment and treatment plan
• Determines and documents participant’s goals
• Engages the participant in the personal health management process
• Engages the PCP and treating physicians in the personal health management process
• Collaborates with the participant and PCP in development of an individualized plan of care
• Develops an ongoing individualized plan of care with timeframes, reasonable and appropriate expected outcomes, specific planned interventions and participant’s goals
• Follows through with interventions and documents outcomes in Current Clinical Status section of care plan
• Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity
• Closes episodes as indicated, i.e. evaluates “Impactability” among other indications for closure.

• UTILIZATION MANAGEMENT

• Reviews daily calendar
• Reviews inpatient episodes and obtain clinical as needed
• Reviews accounts for pre-service requests
• Determines priority of pre-service request
• Complies with and document all pre-service time lines
• Refers requests that cannot be approved to the Medical Director
• Confers with Medical Director for any case of concern regarding treatment patterns or pre-service request.
• Generates adverse decision letters to the affected provider and participant
• Attaches all documents submitted by the provider to support medical criteria for approval of the pre-service claim
• Provides telephonic notification of adverse decision on a pre-service request within policy guidelines.
• Determines appropriate review strategy as identified by the various group health contracts: Preadmission review; Concurrent review; Retrospective review; Pre-certification/Pre-notification
• Identifies and utilizes the applicable utilization review/management tools, while performing pre-certification/pre-notification/clinical reviews: Milliman Care Guidelines; ETGs’
• Ensures and coordinate participant services are at lowest level of service that meet the participant’s needs
• Promotes efficiency of hospital/provider services
• Promotes discharge planning

• MEDICAL MANAGEMENT NURSE EDUCATION AND DEVELOPMENT

• Plan and conduct the initial in house orientation training for Medical Management Nurses
• Collaborate with Director of Population and Personal Health Management and Director of Medical Management Quality to evaluate and improve the initial training as needed
• Plan and conduct the 3 month ongoing orientation training for Medical Management Nurses
• Conduct at least one comprehensive QA review of each orientee within the three month orientation period
• Collaborate with Director of Population and Personal Health Management and Director of Medical Management Quality to evaluate and improve the ongoing training as needed
• Identify and report to Director of Medical Management Quality potential areas of growth for all Medical Management Nurses
• Work with other members of IMMS Management and QM department to plan, coordinate and provide training opportunities
• Report orientation progress and continued training needs for each Medical Management Nurse to the appropriate Team Leader

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Current active professional license in the state of residence
• Eligibility for unrestricted professional licenses in all states
• Competency in Microsoft Word
• Competency in using email, attachments
• Excellent verbal communication skills with the ability to communicate with participants and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, account managers, brokers, customer service staff, IMMS executive management, other IMMS Medical Management nurses, hospital utilization review nurses, etc.
• Excellent written communication skills with the ability to write in a professional, business manner
• Ability to analyze and resolve complex problems
• Excellent organizational and prioritization skills
• Excellent time management skills
• Ability and willingness to function as part of a team
• Ability and willingness to function independently
• Flexibility and willingness to change
• Understanding of IMMS holistic approach to medical management
• Understanding of the client’s (customer’s) perspective and needs
• Understanding of legislative acts, such as the ADA

Include minimum education, technical training, and/or experience preferred to perform the job.

Bachelor degree and CCM preferred. At least 1 year of experience as a Personal Health Nurse (PHN) at InforMed required. A CCM is required within one year of accepting this position. While in the role of the PHN demonstrated the following:

• The ability to perform the role effectively as communicated through reviews of work performed by the Team Leader and QA department
• The ability to practice in the four areas of management – information, population, participant, and financial
• The ability to effective interface with the client and the account managers in demonstrating the outcomes of IMMS interventions
• The ability to effectively communicate in all levels of interaction, both verbally and in writing

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Speaking: Expressing or exchanging ideas by means of the spoken word. This includes activities in which the reviewer must accurately and concisely convey detailed instructions or abstract concepts to clients, other employees, and audiences.
• Hearing: Ability to receive, process, understand and act upon complex materials through spoken language
• Lifting: Moving moderately weighted objects from one position to another
• Fingering: Working primarily with fingers and the whole hand or arm, as in handling, typing, etc
• Ability to enter/retrieve data on personal computer as position requires extensive use of computer
• Sedentary work in the office

TRAVEL

• Ability to travel to the InforMed Annapolis office for all orientations and other in office trainings as needed.

OTHER REQUIREMENTS

• Must meet the requirements for employees working in the Annapolis office, including U.S. Citizenship.

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.