High Cost Case nurses continually initiate, monitor, update, and identify cases for high cost management and reporting. Through all avenues of care coordination, members are identified who are at risk for or have incurred high cost medical care. HCC nurses will also review complex cases such as muscular dystrophy, cancers, AIDS, and autoimmune disorders. A summary is created to allow the client to understand current and future cost drivers. All reviews and reporting are addressed and updated on a continuous basis.
Essential Roles and Responsibilities
% of Time Spent
Evaluate appropriately identified members for cost containment strategies such as network utilization, Site of Care opportunities, external vendors, appropriate precertification, and clinical engagement
Leveraging clinical expertise to assess standards of care in relation the high cost driver. The nurse will review the treatment plan to ensure there is a defined care path. This includes Case Management and Disease Management opportunities and care gaps, as well as Utilization Management opportunities including readmissions, Site of Care, and ER utilization
Create a case summary based on the case history, current state, and future needs including estimated costs and future cost analysis.
Reevaluate cases on a cyclical basis based on new clinical needs, claims, and other relevant data.
Manage stop loss clinical information requests via the email box [email protected]
Address CEG questions, clinical requests, and client specific needs on an ad hoc basis.
Collaboratively work with all aspects of Care Coordinators at Quantum Health to ensure the highest level of quality and care.
Skills and Qualifications
- LPN with a minimum 2 years of experience in a clinical setting
- Active license in state of Ohio
- Aptitude to research and identify issues using critical thinking
- Driven to work independently with limited need for daily supervision
- Utilize nursing judgment to ensure timely and thoughtful decisions, focused on achieving results consistent with business goals and organization culture.
- Perform as a team member with the working group, interact professionally with other entities both internally and externally.
- Proactively present issues and ask questions
- Proficiency with computer skills, navigating multiple systems, and Microsoft applications
- Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
- Effective communication skills, both verbal and written.
- Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies
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