Clinician (Relationship Team)
Identification of adequate levels of care for customers with complex cases, especially those that require additional actions to successfully coordinate the discharge plan in collaboration with Third Parties where applicable. Including but not limited to Medical Necessity, Length of Stay, Place of services and Readmissions. Ensures members have a smooth transition to the next level of care and guarantee all the parts involved work harmonically, with fluid communication and clear expectations.
Has a comprehensive understanding of the Regional health industry (MX, SA or CA & ROW). Liaises with Third Parties where needed/established. Communicates medical decisions to provider, member, agent, region, etc as needed. Provides support to Regional Medical Team through Quality reviews, guidance, medical evaluations as assigned between teams. Provides follow up of complex cases and collaborates with Clinical Escalation Managers and Regional Asesores Medicos Sr.
- Provides an adequate case evaluation for members who require medical care of an acute, chronic or catastrophic nature, by identifying adequate service levels for customer.
- Coordinates with the corresponding providers the discharge plan. Performs discharge planning activities including, but not limited to, approving and arranging home health care, rehabilitation services, (inpatient and outpatient, sub-acute, long-term care, acquisition and delivery of medications according to insured’s policy provisions.
- Communicates proactively with Clinical Escalation Managers, Customers, internal departments and providers; as established in the process guidelines and as needed based on each situation.
- Assists MST in the utilization and understanding of Clinical Managements tools. Ex. InterQual.
- Conducts, when required and coordinated with the Regional Manager, on and off site audits of member’s medical records both concurrent and retrospective.
- Following MST SOP, documents all conversations with providers and physicians, medical record reviews, any phone calls pertaining to patient care to ensure information is available companywide.
- In Charge of passive cases (Non-emergencies, not active admission) that requires additional reviews captured in department’s flows such as PDOC, P25, PPI, FYC.
- Clear and consistent communication skill capable to builds rapport with Hospital, Physicians, Social Workers, and earns their trust and respect to facilitate the gathering of information and enhance the company image and the care of the patient.
- Identification and escalation of potentially fraudulent activity identified at the time of the evaluation process.
- Prepare case information for re-insurance purposes for all BGLA cases.
The Ideal Candidate
- International Medical Graduated and/or valid Register Nurse certification in state of practice is required.
- 2-3 years of nursing/medical practice experience required
- Bilingual English/Spanish; Portuguese helpful with exceptional verbal and written communication skills.
- Case Management certification is a plus