At Lancaster General Health, our culture is what sets us apart and creates a lasting impression of our health system in the community and in the hearts of our patients and their families. A role with us is more than just a job, we ask that you Live Your Legacy at LGH by finding your passion in your everyday role, committing to those you serve, and reaching for your personal best.
We are recognized as 1 of only 9 hospitals in the entire country with awards in Medicare.Gov, LEAPFROG and Healthgrades Americas 50 Best Hospitals. We have attained five year Magnet ® recognition status for the fifth time with the American Nurses’ Credentialing Center (ANCC) and we are the 2018 recipient of the Foster G. McGaw Prize in recognition of the commitment to community service.
PENN MEDICINE LANCASTER GENERAL HEALTH offers a comprehensive benefits package:
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program so that our employees can stay actively engaged and committed to living their legacy every day. Together, we will continue to make medical advances that help people live longer, healthier lives.
Join us and be part of a team that empowers you to do more than your job and encourages you to:
Live Your Passion. Live Your Best. Live Your Commitment. Live Your Legacy.
HOURS: Full Time
**This position is with Preferred Health Care
SUMMARY: Performs network utilization management functions, including quality assurance.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.
- Obtain and input clinical and demographical information according to PHC’s policies and procedures for medical services requiring certification such as preadmission, admission, concurrent and retrospective review in PHC’s system.
- Perform Utilization Review of patient admission, concurrent review, discharge, outpatient services, out-of network requests, and Patient Care calls according to PHC’s approved criteria and policies and procedures.
- Administer client specific programs on the phone according to PHC’s policies and procedures and client requirement. Document activities in utilization review system.
- Perform referral to Case and Disease Management when appropriate or as identified on the weekly Potential Large Case Management report and Large Dollar Claimant report.
- Respond to telephone inquiries from patients, hospitals and clients by providing necessary information within 24 hours.
- Use PHC approved clinical guidelines and nursing judgment to make independent decisions on whether or not a patient meets guidelines for medical necessity. Refer cases to Medical Director that do not meet the criteria.
- Act as a resource and backup for other Care and Intake Coordinators in review process.
- Maintain confidentiality of patient information and PHC proprietary operational information.
- Interface with claims examiners and Payor utilization review staff regarding utilization management issues such as coding issues when there is a discrepancy between diagnosis/ procedure submitted on claim form versus precertification information and questions regarding potential high cost cases and precertification’s. Assist client with clinical issues as appropriate.
- Serve as liaison between PHC Participating Providers and non-network providers, including oversight of out–of–network referral processes when necessary.
- Participate in project work groups, including system development activities, as assigned.
- Comply with all DOL, NCQA and URAC regulations and timeframe requirements.
- Additional duties as may be assigned.
To perform this job successfully, the Care Coordinator must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
- Minimum educational degree is AD degree in Nursing, although a BS is preferred.
- Current license to practice Nursing in the Commonwealth of Pennsylvania.
- Two years clinical nursing experience within the last five years.
- One year discharge planning, utilization review or care manager experience.
This position is located in Lancaster, PA.
Benefits of Joining Penn Medicine Lancaster General Health:
PENN MEDICINE LANCASTER GENERAL HEALTH combines a Nationally Ranked Hospital with great schools, safe neighborhoods, affordable housing, local community events and festivals as well as a wealth of cultural and recreational activities. The scenic Susquehanna River Valley provides opportunities for fishing, skiing, kayaking, hiking and mountain biking in addition to easy access to NJ shoreline or Delaware beaches. Urban life is easily accessible, with New York, Baltimore, Philadelphia and Washington D.C. a train ride away. Local universities, Fulton Theatre, the downtown shopping and dining district and local sports teams make Lancaster a great place to Live, Work and Play.
PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.
Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.
Posted on 11/09/2021