Onsite Clinical Navigator; Hybrid

Resp & Qualifications

PURPOSE: The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG, in addition 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 liaison working onsite at the assigned hospital up to 5 days per week and occasional weekend work may also be required, both at management's sole discretion. Such work will be conducted with the hospital care team including case managers, social workers and discharge planners to ensure Care First members/enrollees receive the appropriate level of care and partner to address any potential barriers to ensure a safe discharge.

Based on hospital assignments and admissions volumes on a week-to-week basis, management may occasionally approve the Onsite Clinical Navigator to perform limited functions telephonically, at its sole discretion. The candidate may also be required to come to the Care First office location periodically for meetings, training, or other business-related activities.
The candidate's primary residence must be within the greater Baltimore metropolitan area
. Bilingual - fluent in Spanish a big plus! This position may be eligible for a role-specific onsite payment differential, which does not apply to other positions.

• Works onsite at assigned hospital facility utilizing clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages onsite with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
• Collaborates with Care First medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. While working onsite to make rounds with members and hospital staff, participates in clinical reviews to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination.
• Makes referrals to other care management programs and vendors as appropriate for chronic, long term care coordination.
• Work collaboratively onsite with hospital teams to develop positive working relationships to decrease provider abrasion and improve member experience.

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 addition to the required work experience.

Licenses/Certifications Upon Hire

Required:

RN - Registered Nurse - State Licensure And/or Compact State Licensure: RN - Registered Nurse in MD, VA or Washington, DC.

Experience
: 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review.

• Knowledge and experience with MCG.
• Experience working with Commercial employer group membership and Medicare/Medicaid enrollees and benefits contracts.
• CCM certification
• MCG certification

• Strong interpersonal skills and the ability to engage in a member facing onsite in-person environment while at the same time building relationships and partnerships with hospital care team and alternative care deliver 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 Microsoft Office applications such as Word, Excel and Power Point.
• Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
• 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 system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).
• The incumbent must have the ability to adapt to change while positively encouraging and motivating…