Medova Healthcare Financial Group, LLC
  • Wichita, KS, USA
  • Hourly
  • Full Time

Medical, dental, vision, 401(k), PTO, paid holidays


Case Management/Utilization Review Nurse is responsible for reviewing patient care from perspectives of medical necessity, quality of care, appropriateness of decision making, place of service, and length of hospital stay within health plan guidelines.

Essential Functions:

  • Develop, implement and evaluate individualized patient care plans, while serving as a liaison between patients, their families and healthcare providers. Update care plans on an as-needed basis, and educate patients and their families on how to follow their care plans.
  • Ensure appropriate utilization management, which focuses on helping members to obtain the right care in the right place at the right time to achieve better overall health. The evaluation is according to established criteria, guidelines, and under the provisions of an applicable health benefits plan. It includes proactive procedures and processes, such as pre-certification, concurrent planning and reviews, peer reviews, discharge planning, and clinical case appeals
  • Review and analysis of clinical data for risk stratification
  • Review health plan documents to determine if requested services are covered by the member's plan
  • Review networks to ensure providers and facilities are in an approved network
  • Assist members in coordinating care and accessing necessary medical services while also containing costs
  • Respond to inquiries from both plan members and healthcare providers
  • Track data and complete logs
  • Provide administrative support such as receiving and logging mail, answering calls, etc
  • Abide by HIPAA regulations and other privacy policies at all times
  • Maintain an exemplary attendance and tardiness record following established company guidelines
  • Demonstrate ability to work well with other departments and all Medova staff members
  • Complete other tasks, as assigned

Competencies:

  • Technical Capacity
  • Customer Service
  • Analysis
  • Problem solving
  • Flexibility

Required Education and Experience:

  • Active LPN or RN license
  • Minimum of 3 years of clinical experience
  • Basic medical coding or claims knowledge

Preferred Education and Experience:

  • Bachelor's degree in a health related field
  • Oncology certified
  • Experience in health insurance industry or case management
  • Experience in a hospital setting

Computer Skills:

  • Microsoft Outlook
  • Microsoft Word and Excel
  • Data Entry

Position Type and Expected Hours of Work:

  • Full-time
  • Monday-Thursday 8am-5pm; Friday 8am-4pm (firm)

Work Environment:

  • Professional office environment
  • Standard office equipment such as computer, phone, postage machine, and copier/scanner/fax
  • Tobacco free
Medova Healthcare Financial Group, LLC
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