Position Summary
Responsible for managing treatment plan utilization and care under the guidance of the SVP and/ or Manager, Clinical Services and Consulting Chief Medical Officer. Reviews clinical records/outcomes to determine appropriateness of care and ensure Company and contract obligations are met.
Essential Functions
Critical features of this position are listed below and may be revised, updated or reassigned at management’s discretion in accordance with business needs or other factors.
- Utilizes ATS for all points of service tracking and documentation
- Confirms member eligibility and IN Network Provider status prior to member engagement
- Confirm benefit details prior to member engagement
- Conducts scheduled and unscheduled consults with members and reviews medical treatment plans based on WIN’s medical and contract guidelines. Consults with Medical Director on unusual cases to determine appropriate referral
- Encourages engagement in WIN App
- Provides care management to include provider navigation, plan of care, BH referrals, augment and/or confirm accuracy of information received from providers to ensure appropriate care, as necessary
- Ensures providers are informed of patient needs, treatment modification, and/or progress when necessary or requested
- Contributes to process improvement on process, the systems, telephone scripts, and educational elements
- Tracks trends, quality of care, protocols and pathways, quality of service reviews to ensure WIN’s protocols are continually improving to meet or exceed ASRM, AUA, and or SMRU guidelines
- Contributes to reporting as needed
- May perform other duties as assigned
Supervisory Responsibilities
No direct supervisory responsibilities.
Minimum Qualifications
- Graduate of an accredited school of nursing with a minimum degree of Associates of Science. Bachelor of Science preferred.
- Current nursing license (and advanced practice license if applicable). Must be licensed to practice as a registered nurse in the state of residence.
- Minimum of five years’ experience in subspecialty including general urology, infertility care management, men’s sexual health.
Knowledge, Skills, and Abilities
- Experience using MS Office products including Word and Outlook.
- Bilingual, Spanish or any other than English language desirable.