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Care Management Review Nurse ID-465

If you're looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we're looking for you.

AtPinnacleClaims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. We are also a proud contracted partner with Covered California. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.

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As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn't a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee's life. One way this is realized for employees ofPinnacleClaims Management is flexible work arrangements with work-from-home, in-office or hybrid options.

With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees' job satisfaction and success.

Compensation: $85,746 - $122,900 with a rich benefits package that includes profit-sharing.


Job Description Summary
This is a high-level clinical position responsible for administering and operating Western Growers Assurance Trust's (WGAT) and Pinnacle Claims Management Inc.'s (PCMI) third-party and direct care management/utilization, health management and case management objectives and initiatives. This position reports to the Nurse Supervisor and requires a high level of clinical judgment and independent decision-making skills.Qualifications
  • BA/BS degree and at least three years experience in working care management programs for companies offering employee health benefits, preferred.
  • Current RN licensure to practice in the State of California, required.
  • Currently licensed as Certified Case Manager (CCM) preferred.
  • Comprehensive understanding of generally accepted medical practices, state and ERISA-mandated benefits, plan language, and contracts.
  • Good understanding of health benefits claims processing, knowledge, and understanding of current procedural terminology (CPT), and international classification of diseases (ICD) 9/10 codes preferred.
  • Ability to develop and present health educational sessions around health, nutrition, and other care management topics is required.
  • Proficient in end-user software programs e.g. word-processing, calendaring, spreadsheet, and electronic health record software required.
  • Knowledge of McKesson end-user software and integration of Interqual medical guidelines preferred.
  • Excellent oral and written communication skills in English and Spanish, preferred.
  • Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
  • Home router with wired Ethernet (wireless connections and hotspots are not permitted).
  • A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
  • A functioning smoke detector, fire extinguisher, and first aid kit on site.
  • Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 5% of the time.


Duties And Responsibilities
Care Management
  • Provide education and coaching to members in the Health Management program.
  • Review and approve referral requests for medical and other specialty services, diagnostic services, and other ancillary services using established medical criteria (per protocol).
  • Develop and implement procedures for determining medical necessity, physician review, and a grievance procedure for both members and providers.
  • Ensure regulatory compliance and maintain routine monitoring and oversight of the organization's case management programs.
  • Provide clinical guidance and oversight of the department's care management activities.
  • Serve as subject matter expert on all care management questions and assist underwriting and claims departments with clinical expertise.
  • Act as a clinical subject matter expert and a point of contact on matters of clinical content.
  • Provide clinical expertise to Product Development in the development of applications and tools.
  • Act as a client-facing clinical subject matter expert and a clinical point of contact.
Medical Review
  • Perform the pre-certification process by obtaining, organizing, and synthesizing clinical, benefit, and network information.
  • Obtain and maintain clinical records from providers and facilities
  • Perform claims medical necessity review.
  • Maintain a positive working relationship with the Provider Maintenance (PM) Department and advise PM of issues with contracting, network, and rosters.
  • Determine when physician advisor involvement is appropriate on a case-by-case basis. Follow-up with the results of reviews sent to physician advisors.
Administration
  • Assist the claims examiners or customer service staff as needed when updating the system notes regarding managed cases.
  • Interact (electronically & telephonically) with employees of other carriers such as Blue Cross and other networks to resolve pricing and contract issues.
  • Provide prognosis reports for the Underwriting Department, as needed.
  • Monitor large dollar case management clients to ensure effective cost savings while assuring the client receives quality health care.
Other
  • Utilize all capabilities to satisfy one mission- to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
  • Maintain a valid California Registered Nurse's License.
  • Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
  • Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
  • Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
  • Attend client or off-site meetings as requested.
  • Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 5% of the time.
  • All other duties as assigned.
Physical Demands/Work EnvironmentThe physical demands and work environment described here represent those that an employee must meet to successfully perform this job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
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