Medical Management Nurse I- LPN

Position Description

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Medical Management Nurse I-LPN works under the guidance and direction of the Clinical Team Lead to provide clinical support to the Utilization Management Units and facilitating the assigned tasks of the unit. The Medical Management Nurse will have need to communicate with both the Member and Provider on a regular basis to meet the clinical needs of the member. The Medical Management Nurse I is responsible for assessing the clinical needs of the members engaged in the Utilization Management Department in Medical Management. Based on clinical assessment, the Medical Management Nurse I is responsible for identifying Members who have complex or ongoing needs and appropriately referring them to other programs / resources.

Responsibilities and Qualifications

• Responsible for maintaining unit service level goals.
• Collaborate with the Medical Director as necessary.@@Complies with Clinical Management and Corporate policies and procedures.
• Identifies and reports potential quality of care issues as established and within the guidelines of intradepartmental processes.
• Maintains Member confidentiality at all times.
• Identifies opportunities and proposes alternatives for improving the Medical Management Programs.
• Promote professional growth of self and other staff members through participation in in-service training, seminars and orientations
• Assists in the orientation of new employees.
• Practices at all times within the scope of appropriate professional and state licensure.
• Prioritizes multiple clinical and administrative tasks and assignments on a daily basis, seeks Team Lead guidance as appropriate.
• Identify members for clinical management programs.
• Document in systems according to established guidelines.
• Maintain a professional relationship with both internal employees and external customers.
• Identifies trends and communicates potential issues to the Clinical Team Lead for follow up.
• Responds promptly and completely to requests for information from the Clinical Management staff.
• Complies with CMS, CMSA, DOH, NCQA, ERISA and PA. Act 68, and other state and federal regulations.
• Attends and participates in company and departmental meetings and training sessions as required.

Skills:

• Ability to operate a personal computer (PC), including proficiency in Word, Access, Excel and Outlook and Clinical Databases utilizing a talk and type method of documentation. Ability to interact with other departments, as needed, to advise, educate and/or direct members to appropriate services.
• Ability to apply critical thinking skills to daily activities.
• Demonstrates openness, flexibility, problem solving, patience, and tact when dealing with Members, family and staff.
• Excellent written and oral communication skills.
• Capable of working independently as well as part of a team

Knowledge:

• Knowledge of URAC and NCQA standards for case management organizations and CMSA Standards of Practice for Case Management, Act 68, NCQA, CMS and ERISA.
• Knowledge of managed care principles and emerging health treatment modalities.

Experience:

• Five (5) years clinical experience working in an acute care hospital or other appropriate clinical setting.

Education and Certifications:

• Licensed Practical Nurse with an active unrestricted Pennsylvania license.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.