Senior Medical Advisor (Night Shift)
In charged to handle all cases received and others that will requires our responses during afterhours (night shift) for preauthorization’s services including those that require additional actions to successfully coordinate the discharge plan. 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.
- Provides case management to members who require medical care of an acute, chronic or catastrophic nature,
- 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.
- Use and understanding of Clinical Managements tools. Ex. InterQual.
- 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.
- Maintains report of all “Big cases” (over 50K) in the corresponding region and recommend actions to guarantee an efficient cost control and great customer experience.
- Monitor high value paid claims to identify cases no captured in the Big claims report.
- 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.
- As part of Medical Services Team, coordinate the procurement of medical records, home health and medical equipment information.
- Identification and escalation of potentially fraudulent activity identified at the time of the evaluation process.
- Prepare case information for re-insurance purposes.
- Performs other duties as assigned.
The Ideal Candidate
- MD or RN certification in state of practice is required.
- 2-3 years of nursing/medical practice experience required
- Bilingual Spanish/English read, write; Portuguese helpful with exceptional verbal and written communication skills.
- Case Management certification is highly appreciated.