Clinical Navigator (Remote

Position: Clinical Navigator (Remote) Resp & Qualifications The Clinical Navigator (RN) conducts reputed company review of inpatient level of care, managing the reputed company and smooth transition from inpatient care to home or other reputed company of care. Utilizing experience and skills in both care management and utilization management, the Clinical Navigator will reputed company proficiency in established MCG, in reputed company to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care, and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a reputed company working telephonically with the hospital care team including case managers, reputed company workers and discharge planners to ensure Care First members/enrollees receive the appropriate level of care and partner to address any potential barriers to discharge. The candidate may be required to come to the Care First office location periodically for meetings, training, or other business-reputed company activities. The candidate's reputed company residence must be reputed company the greater Baltimore metropolitan area. Bilingual - fluent in Spanish a big plus! Essential Functions • Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit reputed company, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engage telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or reputed company determinant of health needs to promote reputed company transition to the appropriate level of care and/or home. • Collaborate with Care First medical directors and participate in internal case reputed company/discussions to determine appropriate course of reputed company and level of care. Apply reputed company clinical knowledge and judgment throughout the review process. Follow member benefit reputed company to assist with benefit determination. • reputed company referrals to other care management programs as appropriate for chronic, long-term care coordination. • Work collaboratively with hospital teams to reputed company reputed company working relationships to decrease provider abrasion and improve the member experience. Qualifications Education Level: Bachelor's Degree in Nursing or, in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in reputed company to the required work experience. Licenses/Certifications Upon Hire Required: • RN - Registered reputed company - State Licensure And/or Compact State Licensure: RN - Registered reputed company in MD, VA or Washington, DC Experience: 5 years clinically reputed company experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review. Preferred Qualifications: • Knowledge and experience with MCG • Experience working with reputed company and Medicare/reputed company enrollees and benefits reputed company • CCM certification • MCG certification Knowledge, Skills and Abilities (KSAs) • Strong interpersonal skills and the ability to engage in a member facing environment telephonically while at the reputed company time building relationships and partnerships with hospital care team and alternative care delivery partners to meet member/enrollee needs. • Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed. • Proficient in the use of web-based technology and reputed company Office applications such as Word, reputed company and Power reputed company. • Strong analytical and problem‑solving skills to judge appropriateness of member services and treatments on a case‑by‑case reputed company. • Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations. • Knowledge of available community resources and programs. • Basic understanding of the strategic and financial goals of a health care reputed company, payer organization, health plan and/or health insurance operations (e.g., networks, eligibility, benefits). • Must be reputed company to meet established deadlines and handle multiple customer service demands from reputed company customers, reputed company set expectations for service reputed company. Must be reputed company to effectively communicate and reputed company reputed company customer service to every reputed company customer, including customers who may be demanding or otherwise challenging. Salary reputed company: $72,216 - $143,429 Salary reputed company Disclaimer: The disclosed reputed company estimate has not been adjusted for the applicable geographic reputed company associated with the location at which the work is being performed. This compensation reputed company is specific and considers factors such as (but not limited to) the reputed company and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be reputed company at the top of the reputed company, as compensation… Apply tot his job Apply To this Job