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Advanced Practicing Nurse / Physician Assistant

Company: Friday Health Plans
Location: Alamosa
Posted on: May 12, 2022

Job Description:

Who You Are

You are a compassionate communicator with strong analytical talents. You have solid interpersonal skills and can make quick judgment calls. You are a multi-tasker and detail oriented. Under the general direction of the Medical Director, this role has primary responsibility for development and daily management of health care service activities related to the delivery of medical care for Friday Health Plan members. The Advance Practicing Nurse / Physician Assistant encompasses utilization management (including case management and referrals), quality management and appeals resolution.

Who We Are

Friday Health Plans isn't your average health insurance company. We're not about unnecessary extras and confusing terminology. We cover the basic health services you'll likely use the most at a price that just might make your wallet happy. Our simple health plans and friendly service keep you covered so you're free to live every day like it's Friday.

As a Denver-based startup company, we're looking for smart, talented people like you to join us. We value collaboration, innovation, passion, and a calculated risk-taking. Now in year four and growing rapidly, we're looking for people who lead by example, and that example is one of flexibility, reliability, and positivity. If this sounds like you, then we want you on our team.

What You'll Do

  • Has responsibility in assisting with the implementation of policies and procedures for the Medical Department
  • Oversee member Wellness Programs
  • Assists as needed in the preparation of quarterly and annual reports for the Medical Director and the Board of Directors, including information about Quality Management (QM) and Utilization Management (UM) activities and denials
  • Ensure compliance with all relevant federal and state statues, regulations, rules and guidelines that pertain to the medical department
  • Provides department metrics as needed to the Clinical Medical Manager for submission to the Quality Management Program Committee.
  • Review and approve referrals and authorizations per established guidelines; involve Medical Director when guidelines are not met or not applicable and deny referrals from providers of similar licensure.
  • Perform concurrent review of hospital admissions and assist with discharge planning on a daily basis. Keep Medical Director and administration informed of census including high-risk and high-cost cases
  • Develop and maintain good working relationships with information management and case management personnel at participating hospitals, clinics and other health care agencies
  • Assist other agency discharge planners in obtaining and coordinating services across the continuum of care (e.g., skilled care, home care, or health education)
  • Work with the Clinical Medical Manager to identify, develop and implement projects related to utilization issues; has primary responsibility for implementation of same
  • Maintain current knowledge of UM and CM guidelines
  • Assists as needed with the Medical Grievance and Appeals process.
  • Have a working knowledge of state and federal grievance and appeals procedures as well as the policy and procedures of Friday Health Plans
  • Provide input into activities designed to improve HEDIS scores
  • Identify and implement case management plans specific to individual needs for selected members in consultation with Medical Director
  • Follow established policies and procedures for UM, CM, and DM (disease management) and assist the Clinical Medical Manager, as needed, for modifications to same
  • Assist with claims processing as requested by the claims department
  • Provide support as needed to the non-clinical members of the department
  • Maintains a working knowledge of all current plan documents
  • Ensures that all clinical denials are handed off to a medical director
  • Other duties as assigned

    Required Knowledge, Skills & Abilities:
    • Ability to balance multiple competing priorities
    • Ability to function at a high level with minimum supervision
    • Excellent organizational skills
    • Strong computer skills, including proficiency in word processing and spreadsheet software, and ability to find and utilize online resources
    • Professionalism and the ability to use diplomacy in working relationships
    • Excellent oral and written communication skills
    • Proven leadership ability, including creation and implementation of new projects
    • Good analytic skills
    • Broad clinical knowledge base to assist in decision making procedures

      Required Education/Experience:
      • Current Nurse Practitioner (APN) or Physician Assistance licensure with a minimum of 2 years clinical experience is required and 5 years is preferred
      • Knowledge of computer and basic office equipment

        How You'll Be Valued:
        • Medical, Vision, and Dental premiums for you and your family covered at 100%
        • Company funded health savings account (HSA)
        • 401(k) and 401(k) matching
        • Company paid life insurance
        • Company paid short- and long-term disability insurance
        • Employee assistance program
        • Paid time off and 10 paid holidays
        • A company culture that is regularly recognized as a Top Workplace by organizations such as CoBiz
        • Salary $94,000 - $104,000

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Keywords: Friday Health Plans, Pueblo , Advanced Practicing Nurse / Physician Assistant, Healthcare , Alamosa, Colorado

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