Nurse Advice Line RN

Manila, Philippines


Reports to: Department Manager


Department: Global Health Services


About Us

Calibrated Healthcare Network (CHN) manages over 11 million lives in over 8 states, partnering with industry leaders in the area of managed care. Our operating model features global workforce strategies, coupled with efficient technological solutions. We have a proven expertise in re-engineering complex managed care business processes to provide value to our esteemed partners. Our commitment to the evolution of healthcare is evident in our investment in research and development for the progression of dynamically enhanced technology to meet the needs of partners. The core suite of services includes Claims Adjudication, Benefits Setup, Member Enrollment and Eligibility Setup, Claims System Configuration, HCC Coding and MSO Development support.

The Calibrated Clinical Solution (CCS) global workplace is built on the concept of providing cost-effective care, enhancing population health strategies, and improving the quality of care. Calibrated Clinical Solutions deploys the use of proprietary software to create cost-effective workforce solutions constructed on the premise of collaboration technology. With our extensive domain of knowledge of managed care and dynamically enhanced technology, we have the capacity to create innovative solutions for our managed care and primary practice partners. Our core suite of services includes Medical Management, Utilization Management, Complex Case Management, and Population Health Management.

Position Description

The Nurse Advice Line RN is an extension of provider offices or medical management operations either during office hours and/or after hours and weekends. The Nurse Advice Line RN is expected to direct members to the appropriate level of care, provide health education and information, provide care coordination, authorization of services, and provide telehealth to an assigned population. The Nurse Advice uses evidence-based protocols and clinical practice guidelines in the management of services for outpatient or inpatient needs.

Education

  • Associates Degree in Nursing
  • Bachelor of Science in Nursing preferred

Licensure/Certification

  • A current active Registered Nurse license issued by the California Board of Registered Nursing
  • Certified Case Manager (CCM) preferred
  • Accredited Case Manager (ACM) preferred
  • Certified Managed Care Nurse (CMCN) preferred

Experience

  • Minimum 2 years clinical practice experience required, preferably in an acute care, ICU, or ED setting
  • 1-year managed care experience preferred
  • Previous case management experience preferred

Job Skills

  • Core Competencies: Critical-Thinking, Ethics and Values, Customer Focus, Action-Oriented, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
  • Demonstrated ability to work together across professions and individuals to improve health outcomes
  • Computer Proficiency (MS Word, MS Excel, MS Outlook, Video Conferencing)
  • Capacity to interpret evidenced based guidelines (Interqual and/or Milliman criteria sets), health plan/client specific chronic care guidelines, and policies/procedures
  • Knowledge of NCQA, DMHC, and state requirements for case management

Essential Functions of Job

  • Must be able to perform the functions of the RN Case Manager and the UM Nurse Reviewer
  • Assessment: Provides a comprehensive assessment to evaluate and identify an individual’s needs an intensity of services based on evidenced-based protocols
  • Planning: Follows established clinical protocols to determine appropriate interventions
  • Planning: Appropriately activates members of the care team based on member assessment to address immediate needs
  • Implementation: Able to follow established guidelines for authorization of services for outpatient or inpatient requests
  • Implementation: Able to instruct members for planned or unplanned transitions (i.e surgeries, procedures, hospitalization)
  • Implementation: Act as facilitator and coordinates of care, services, resources, and health education specific to the member’s needs
  • Evaluation: Ensures implemented interventions align with member’s needs and documents action appropriately
  • Closure: Refers complex cases to case management for ongoing follow-up
  • Closure: Ensures compliance with desktop procedures for appropriate documentation
  • Participates in concurrent and retrospective quality assurance activities
  • Performs outbound calls for the Population Health Management or Utilization Management program as assigned
  • Performs additional duties as assigned

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