EDUCATION: Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing.

CERTIFICATION/LICENSES: Current RN Nursing license

Interqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferred

SKILLS:

• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
• Intensive writing capabilities/efficiencies
• Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff)

• Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
• Assertive and diplomatic communication, proven ability to function on a multidisciplinary team
• Excellent organizational skills including effective time management, priority setting and process improvement

• Ablility to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicable
• Understanding of Medicare, Medicaid and third party reimbursement methodologies

• Ethics and Values -- Adheres to an appropriate (for the setting) and effective set of core values and beliefs during both good and bad times; acts in line with those values; rewards the right values and disapproves of others; practices what he/she preaches
• Creativity -- Comes up with a lot of new and unique ideas; easily makes connections among previously unrelated notions; tends to be seen as original and value-added in brainstorming settings
• Customer Focus -- Is dedicated to meeting the expectations and requirements of internal and external customers; gets first hand customer information and uses it for improvements in products and services; acts with the customers in mind; established and maintains effective relationships with customers and garnishes their trust and respect.
• Decision Quality -- Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.
• Drive for Results -- Can be counted on to exceed goals successfully; is constantly and consistently one of the top performers; very bottom-line orientated; steadfastly pushes self and others for results.
• Peer Relationships -- Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.
• Priority Setting -- Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.

EXPERIENCE: Two to four years of Case Management experience. Two to three years' experience in the denial and appeal process. Experience with managed care, governmental and/or RAC appeals strongly preferred. Computer experience in Microsoft Office (Word and Excel).

NATURE OF SUPERVISION:

-Responsible to: Director of Case Management

ENVIRONMENT:

-Bloodborne pathogen: A

Works in a clean, well-lighted, ventilated smoke-free environment.

PHYSICAL REQUIREMENTS: Vision acuity at least 20/40; hearing acuity at least conversational; color perception. Lift/Carry objects more than 40 lbs. per day.