Job Description:

• This field-based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.

Responsibilities:

1. Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.

2. Evaluates the necessity, appropriateness and efficiency of service provided.

3. Develops, coordinates and assists in implementation of services to meet the needs of the members.

4. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

5. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.

6. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

7. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

8. Refers members to MLTSS when appropriate.

9. Educates members on the availability of SNP if appropriate.

10. Documents accurately and comprehensively based on the standards of practice and current organization policies.

11. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.

12. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

13. Completes other assigned functions as requested by management.

14. Performs duties as assigned by management.

Experience:

• Field RN Experience

Skills:

• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

Education:

• Bachelor’s degree

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com) .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.