Care Coordinator -RN Required

Aug 21 2017
TriWest Healthcare Alliance |Honolulu|Full Time
Category: Healthcare
Job Description


Conducts Medical / Surgical or Behavioral Health medical necessity reviews for continued stay reviews, care coordination, discharge planning, and post-nursing calls.  Conducts review and pre-screening reviews for Medical Director prior to non-certification.   Initiates discharge-planning care coordination and post-service nursing calls. Utilizes clinical and analytical skills to identify and refers cases to Case Management or Disease Management as appropriate.  Provides support to non-clinical staff on clinical and coding questions.  Conducts pre-admission screening assessments.


Government Reporting






Education & Experience




o        Registered Nurse, with current unrestricted license in appropriate state or territory of the United States.
o        2+ years experience in clinical nursing experience
o        Proficiency in medical data entry and Microsoft Word
o        Exceptional oral communication skills




o        3 years clinical experience
o        2+ years Managed Care experience 
o        Knowledge of Intensity of Service and Severity of Illness indexes; InterQual Imaging Criteria, Procedural Criteria, Level of Care, and Length of Stay; International Classification of Diseases; Current Procedural Terminology; and Health Care Financing Administration Common Procedure Coding System; and American Dental coding


Key Responsibilities


Key Responsibilities


o        Coordinates discharge planning, completes necessary authorizations, and conducts post-service nursing calls.
o        Conducts Utilization Management continued stay and inpatient reviews to assess medical necessity.
o        Researches and collaborates with appropriate community resources to support discharged beneficiaries.
o        Prepares more complex cases for Medical Director and Peer Review.  Collaborates with Medical Director on decision-making.
o        Utilizes clinical and analytical skills to identify and refers cases to Case Management or Disease Management as appropriate.
o        Communicates with providers to develop plan of care.
o        Conducts complex authorizations for beneficiaries in acute, residential treatment center, skilled nursing facilities, or long-term acute care hospitals.




o        Identifies and reports potential quality or fraudulent cases to Internal Audit & Corporate Compliance department or Clinical Quality Management for review.
o        Participates in focus group studies as requested, including the development and implementation steps.
o        Supports other regional hubs as needed.
o        Perform other duties as assigned.
o        Regular and reliable attendance is required.




Technical Skills


Thorough knowledge of internal policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, and medical management on-line system.  Proficient with Intensity of Service and Severity of Illness indexes, InterQual Imaging Criteria, Procedural Criteria, Level of Care, and Length of Stay, Clinical Decision Support Tool, International Classification of Diseases, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding.  Ability to meet or exceed production standards in compliance with contract


Problem Solving / Analysis


Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.


Organizational Skills


Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.


Empathy / Customer Service


Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.


Coping / Flexibility


Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.


Computer Literacy


Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.


Communication / People Skills


Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.


Commitment to Task


Ability to conform to established policies and procedures; exhibit high motivation.


Working Conditions


Working Conditions


o        Availability to work any shift
o        Works within a standard office environment, with minimal travel
o        Extensive computer work with prolonged sitting
o        Department of Defense security clearance required