4C11
MANAGED CARE NURSE

This is administrative nursing work, coordinating the delivery of managed health care services and reviewing and evaluating the quality and level of services provided. Employees in this class function as liaison to health maintenance organization representatives and health care providers to ensure the effective delivery of managed health care services. Work includes ensuring adherence to provider organization administrative requirements and related departmental policies and procedures. Work also involves developing and maintaining reference manuals on health maintenance organization providers and service requirements, coordinating the managed care referral process, and serving as a resource to staff and patients on issues relevant to managed care.

Contact with patients, facility and hospital staff, and health maintenance organization representatives is a significant aspect of the work. Work is performed under the direction of a technical nursing superior.

1. Employees must provide managed health care services for a Health or Human Services agency or a correctional institution.
2. Positions in this class must coordinate the delivery of managed health care services, reviewing and evaluating the quality and level of services provided.

• Coordinates the provision of health care services associated with a variety of managed health care plans; functions as liaison between district health center, health care providers and health maintenance organizations on matters related to the delivery of managed health care; reviews specialist referrals and ensures that referrals completed by other health center staff are accurately completed and signed by a physician in accordance with health maintenance organization requirements; reviews pre-approvals for hospital admissions and special procedures; ensures that appropriate documentation, diagnostic test results and other patient information are forwarded to health care providers as required.
• Responds to requests for information from hospitals, health facility staff, and patients on issues related to managed health care services and administrative requirements; obtains physician authorization for emergency treatment of managed care patients as required; maintains records of emergency calls received and treatment authorized; provides assistance to managed care plan and other patients in accessing services provided at district health centers; verifies eligibility for services for managed care patients; schedules patient appointments with specialists as designated by managed care plan; monitors EPSDT (early periodic screening and diagnostic testing) status of pediatric patients enrolled in managed care plans; develops mechanism to ensure that appointments are made for required pediatric health care services.
• Develops and maintains reference manuals on health maintenance organization providers and service requirements; maintains listing of district health center patients enrolled in managed care plans.
• Meets with health maintenance organization representatives to discuss issues and procedures related to the delivery of managed health care services and related administrative requirements; meets with medical, nursing, administrative and support personnel to resolve problems and discuss new procedures and policies pertaining to the administration of managed care plans.
• Evaluates the provision of patient services in accordance with program policy; monitors and reviews provision of patient services; evaluates and ensures the application of health care principles and practices and applicable professional standards; makes recommendations to improve standards of care and the quantity and quality of patient services; reviews the work performance of the health services delivery staff; reviews reports submitted by contracted providers; implements standards for nursing and patient care; makes recommendations for facility changes to bring nursing and patient care up to desired standards; makes personal inspection of clinic and infirmary areas; reviews selected records to ascertain whether services were provided and recorded properly.
• Participates in quality assurance reviews and patient surveys as required by health maintenance organizations; attends quality care committee meetings; provides information required for the audit and evaluation of managed health care services; develops recommendations to provide for more effective and efficient coordination of managed health care activities.
• Coordinates the provision of medical services for municipal employees who have received service-connected injuries through multiple site, contracted medical care providers; contacts the appropriate departmental safety office regarding questionable referrals; reviews treatment plans submitted by contracted providers; determines if treatment prescribed is consistent with injuries determined to be job-related; contacts the provider for clarification and/or to stop treatment; reviews modifications to treatment plans; approves or disapproves accordingly.
• Keeps informed of, and evaluates federal, state and private sources for funding of services and research; interprets funding laws and regulations and advises health and welfare agencies in procedures for submitting applications.
• Performs related work as required.