4C12
MANAGED CARE NURSING SUPERVISOR

This is supervisory nursing work, providing direction to a small group of managed care nurses and participating in the delivery of managed health care services. Employees provide technical direction and policy guidance to nurses engaged in the review of managed health care. 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.

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 direction to a small group of nurses providing 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.

• Assigns work to a small group of registered nurses; supervises work by observation and evaluates work performance; trains and instructs nurses in the protocol to be followed in the health care program.
• Coordinates the provision of health care services associated with a variety of managed health care plans; functions as liaison between health facility, 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 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.
• 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.
• Conducts audits on selected procedures and activities; researches and establishes criteria for audits; 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.
• 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.

KNOWLEDGE OF:
• current nursing theory, principles, practices and techniques
• literature and current developments in the nursing field as applied to ambulatory health care
• the resources available to persons in need of related health and social services
• the systems, methods and techniques of patient care in an ambulatory health services facility
• the principles and practices of managed health care
ABILITY TO:
• supervise a small group of managed care nurses
• coordinate the provision of health care services associated with a variety of managed health care plans
• evaluate and resolve problems related to the administration of managed health care services
• maintain current records of health maintenance organization providers and service requirements
• develop recommendations to provide for more effective and efficient coordination of managed health care activities
• prepare, process and maintain records of managed care referrals
• obtain information from patient records
• use personal computers and software packages as required by assignment
• establish and maintain effective working relationships with patients, health care providers, and health maintenance organization representatives
• maintain an empathetic attitude toward and harmonious relationships with patients and the public

EDUCATION
• Graduation from an accredited school of nursing.
AND
EXPERIENCE
• Three years of nursing experience, two years of which has included managed care nursing experience.

• Ability to physically perform the duties and to work in the environmental conditions required of a position in this class.

• Possession of a license as a Registered Nurse by the Pennsylvania State Board of Nurse Examiners prior to appointment.