A Case Manager Nurse uses the nursing process to plan, implement, and evaluate the quality of patient care, and the use of resources. A primary focus is to monitor the quality of care in order to assure that there are appropriate levels of risk management. As a Complex Case Manager Nurse, you would also act as an advocate for patients and their families, and work with medical facilities such as hospitals and assisted living facilities. A Complex Case Manager Nurse facilitates the care of patients with complex issues such as mental health or substance abuse.

Job Duties

• Acts as a primary source of care for patients with complex health needs, with a wide range of engagement
• Conduct clinical assessments over the phone to address the health and wellness needs of patients using a set of clinical interviewing skills
• Develop care plans based on patients specific needs by using the clinical information system to establish treatment goals
• Communicates with the patients other care providers in more complex situations requiring case management intervention.
• Serves as a subject matter expert to clinicians to provide education, consultation, and training when needed
• Incorporates lifestyle improvement and prevention opportunities into member interactions

Education and Qualifications

• Ability to work a flexible schedule
• Current RN license is required
• Generally, a Case Management Certification (CCM) is preferred
• A Bachelor’s or Master’s in Nursing is also a preferred qualification
• At least some experience working with the healthcare needs of a variety of people

A Clinical Appeals Coordinator’s primary role is to act as a liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. The Clinical Appeals Coordinator is also responsible for ensuring that all appeal letters that are generated comply with all requirements, whether they be State or NCQA requirements

Job Duties

• Reviews clinical information for all appeals by using criteria that is nationally recognized, in order to determine the actual necessity of the services that are requested
• Prepares reviews for cases that do not meet the required criteria
• Coordinate and deliver verbal and written information regarding patient and provider appeals, and ensure all letters are in line with all required standards
• Maintains files and logs related to all appeals
• Coordinates hearings with various internal departments and agencies

Education and Qualifications

• For some positions, a RN certification is required, or LPN with more experience may be substituted in some situations
• Generally, at least a few years of clinical nursing or case management experience is required, with more being required for LPN applicants
• Managed care experience or utilization review experience preferred for some positions

A Client Services Specialist in the healthcare field is ensures that patients and clients have a positive experience. They act as a liaison between the company and its clients, in addition to assisting with complaints, orders, account questions, billings, and cancellations. A Client Services Specialist also assists Account Managers to ensure a high level of customer service.

Job Duties

• Brings in customers through answering questions about products or services, as well as suggesting information about other products and services
• Builds, maintains, and improves relationships with clients through regular communication
• Processes documentation based on orders received from clients
• Tracking and recording project progress in multiple CRM systems
• Manages projects through their entire duration
• Assists with other duties and projects as needed

Education and Experience

• A Bachelor’s degree in a related field of study such as Business administration is required
• Strong working knowledge of the healthcare industry is generally preferred
• Proficiency in Microsoft Office applications such as Word, PowerPoint, Excel, and Visio is a must
• The ability to manage multiple projects at one time
• Excellent interpersonal skills are required

A Claims Researcher in the healthcare field works to review insurance claim files to ensure that carriers are exercising their practices in an efficient manner. The Claims Researcher works to produce reports on a daily, weekly, and monthly basis in order to summarize their findings.

Job Duties

• Reviews claim files and reports on the performance levels of services provided by insurance carriers, using a thorough understanding of insurance adjusting practices
• Ensures all claims are handled properly by maintaining a claims management diary system
• Resolves any questions the client or patient may have in regards to the claims process, claims status, and settlements
• Works to ensure that claim submissions that require research or special handling are processed efficiently
• Reconciles claim reserves on a weekly basis to ensure proper tracking and reporting

Education and Experience

• Generally, some college experience in a related field of study such as business or marketing is preferred
• A valid Insurance Adjuster’s license is required
• At least a year of insurance claims adjusting experience is required for most positions
• Impeccable customer service, organizational, and analytical skills are a must
• Possession of excellent written and verbal communication skills needed
• A strong working knowledge of Microsoft Word and Excel is required

A Claims Manager in the healthcare field manages and administrates direction of billing for medical services provided to patients in order to ensure they receive care in the most efficient manner. They work to plan, organize, and direct a medical claims department. A healthcare Claims Manager also coordinates with representatives of outside agencies, and members of the public by providing accurate information in an efficient manner.

Job Duties

Essential functions of a Claims Manager in the healthcare field include, but are not limited to:

• Monitoring billing activities, performance management, and production standards and quality of results
• Providing technical assistance to staff in order to initiate billing to all appropriate payer types
• Analyzes data for bill presentation based on requirements and reviews claims for quality
• Works to prepare or supervise the preparation of processes and bill presentation to ensure quality and accuracy
• Stays up to date on State regulations, and implements changes regarding claims and billing requirements

Skills and Education

• A knowledge of Federal, State, and County codes related to fiscal operations of Health Services
• A knowledge of basic medical terminology
• Ability to analyze and interpret problems in data collection, billing, and accounts receivable
• A bachelor’s degree in a field related to managing claims in the healthcare field such as business administration, accounting, finance, or a related field
• Minimum of a few years of experience in healthcare organization, or processing medical claims is generally required
• Experience in the field above what the minimum requirement is may substitute for some education

A Claims Liaison in the healthcare field serves as the claims payment expert for a company in the healthcare field such as a hospital, clinic, or nursing facility. One of the main focuses of a Claims Liaison is to act as an intermediary between various healthcare services and clients or patients by offering information and education about those services. The Claims Liaison should be able to explain things clearly to their clients and patients with excellent communication skills, in order to build long-lasting relationships with them.

Job Duties

The primary duties of a Claims Liaison in the Healthcare field includes, but may not be limited to:

• Preparing reporting related to claims in a timely manner
• Identifying discrepancies in payments, as well as payment updates
• Work to ensure that claims are processed in a timely manner, and that they are processed in accordance to proper policies and procedures
• Demonstrate a strong knowledge of all relevant products
• Apply any applicable policies, procedure, or guidelines as needed

Skills and Education

• In some instances, a High School Diploma or GED may be acceptable when coupled with appropriate amounts of previous experience
• A minimum of 4 years of experience in a related field such as claims adjudication, or auditing experience required. A Bachelor’s degree in a related field may be substituted for some experience
• Demonstrate strong interpersonal skills, as well as excellent written and oral communication abilities
• The ability to work under pressure and multi task is strongly recommended

A Healthcare Case Manager ensures the quality care of their clients by promoting quality, cost-effective outcomes. They provide management services to children, families, and other caregivers in a variety of settings such as hospitals, assisted living facilities, home, or school to ensure the services they receive are appropriate for their specific needs. A Healthcare Case Manager also works with the families of their clients to make sure care arrangements are in line with the needs and wants of the entire family.

Job Duties

• Engaging clients and families in developing positive, trusting relationships
• Help to manage any emotional distress on the part of the client or their family in resolving crisis situations. Use incredible discretion and judgement when determining an appropriate course of action.
• Maintain the ability to compare and evaluate possible courses of action as required by specific circumstances
• Build and maintain relationships with clients, as well as business type relationships with outside care companies
• Demonstrate great interpersonal skills and ability to work with patients with mental illnesses or emotional disturbances.
• Manage conflict, promote change and growth, and facilitate the growth of all patients
• Use strong collaborative abilities to put together plans for patient care by working with patients and their families to discover their specific needs, and coordinating with outside companies to ensure proper care

Qualifications

• Generally, a Bachelor’s degree in a related field such as human services, with an emphasis in social work, psychology, or rehabilitation is preferred
• A strong familiarity with mental health theory or emerging promising practices is preferred
• Some experience in providing case management support is generally preferred
• Strong interpersonal and communication skills are a must
• Demonstrated strong time management and organizational skills.
• The ability to multitask and manage multiple projects at once time is strongly recommended

A Business Analyst in the Healthcare field would support the development and quality of the healthcare platform. They would have an extensive knowledge and experience in diverse environments and applications. A Business Analyst has the ability to discuss industry and marketplace trends and directions, and cite relevant case studies. They are able to manage a wide variety of projects of varying complexity simultaneously, and is able to manage cross-functional projects and teams.

Job Duties

• Conduct research and stays current on quality measures, evolving healthcare policies, and clinical guidelines to understand needs and opportunities of the business
• Identify key policies and requirements that the organization will need to comply with
• Utilize subject matter expertise to help maintain business requirements
• Convey product features and benefits to stakeholders included but not limited to IT, operations, and management
• Oversee projects to see initiatives through to execution
• Perform additional duties as necessary and assigned by management

Qualifications

• Generally, a bachelor’s degree in a related field is required in a related field, or experience equivalent
• Experience in managed health care is preferred
• A minimum of a few years healthcare business process experience
• Thorough knowledge of the Microsoft suite of applications
• Project management experience preferred
• Excellent critical thinking and analytical skills

A behavioral case manager in the healthcare field is primarily a social worker who works with clients who have behavioral disorders such as, drug or substance abuse, eating disorders, or other mental illnesses detrimental to their health. They are responsible for creating and coordinating treatment plans suited to each individual client. Helping clients achieve their set goals and overall success are cornerstones of being a behavioral case manager.

Education

• A current, unrestricted RN license in your state of residence is required
• Entry level behavioral case manager positions require a Bachelor’s degree at the very minimum, and often require at least some experience in a related healthcare field such as acute care or coaching members with psychiatric disorders
• Mid-level and higher behavioral case manager positions require a Bachelor’s degree in a related field, and a few years’ experience in case management and a related field like case management or coaching members with psychiatric disorders is required.

Job Duties

• Creation of both long and short term treatment plans for clients
• Assisting clients to set achievable goals to aid in their recovery
• Coordinate resources required to help clients achieve success
• Education and support of the client through both face-to-face assessment and home visits
• Assesses and fixes gaps in client care, and determines additional needs or requirements related to a specific clients disease or disorder

As a behavioral healthcare coordinator/behavioral health coach, you would be assisting psychiatric providers on a day to day basis to coordinate patient visits and working with patients to reduce no-shows. You would be a core member of a care team that includes the patient’s primary care provider, psychiatric provider, and mental health provider that works to ensure the quality of care for the patient. You would be responsible for having a working knowledge of both local and state behavioral health, medical, social programs, and other resources in order to serve as a liaison between patients and providers.

Education/ Experience

• Some positions in this field allow a High School Diploma or GED, but generally a Bachelor’s degree in a related field such as social work is desired
• Minimum of about a year of experience in psychiatric patient care coordination or working with behavioral health patients is required
• For some positions, the ability to be insured is required
• Some positions require a current CPR certification

Job Duties

• Provide assistance to psychiatric providers in the form of answering the phone and taking messages
• Taking vital signs and reporting to physician provider for interpretation
• Interviews patients and obtains basic information
• Assisting patients with scheduling appointments
• Responsible for meeting with patients who no-show to develop personalized plans to help eliminate no-showing