Summary

Under minimal direction, provide clinical expertise to staff, management and customer within a health care account. Act as liaison to customers, providers, and recipients by resolving problems and clarifying medical and healthcare issues. Recommend and promote beneficial changes to customer programs to promote access to quality care and control of benefit packages. Assist in adjudication of medically complicated claims. Participate in customer’s policy development. Provide assistance in drafting provider manuals, bulletins, and revisions to promote publication. Assist with organized healthcare groups and associations on various medical issues related to the State’s medical program. This clinician will be part of the Prior Authorization team. The team has the responsibility for the following: to review, assess, and pre-approve selected non-emergency medical services prior to the actual delivery. The clinician is to help with cost containment and utilization review measures to make payment for only those treatments and services that are medically necessary, appropriate, and cost effective. The clinician provides support to the case management functions by accepting treatment plans as a form of prior authorization. Other duties may be assigned as required.

Your role in our mission

• Provides nursing care for serious occupation and non-occupational injuries and illnesses, based upon nursing assessment, nursing diagnosis and medical directives.
• Investigates quality and quantity of provided health care to determine adherence with company and governmental policies. Provides nursing care for complex occupational illnesses and injuries at various worksites including emergency care and referrals.
• Develops and maintains nursing policy and procedure manuals and ensures that information is communicated to appropriate personnel in an accurate manner. Investigates the potential for improvement, and develops and implements new procedures.
• Serves as case manager for on-site injuries and follow-up care. Assists in determining extent or seriousness of work-related injuries. Administers basic first-aid and assistance and contacts appropriate authorities regarding decisions related to further actions.
• Maintains health related documentation such as employee medical records. Tracks and records exposure to hazardous environments or chemicals and common injuries to ensure prevention of future occurrence. Provides counseling on routine health subjects and referrals to other health care professionals.
• Supervises Guides less experienced staff in the delivery of health care consistent with nursing practice standards and established company policies; ensures that appropriate care is provided in a timely manner.
• Interfaces with line management, safety and industrial hygienists and human resources personnel regarding resolution of pending medical claims or cases related to on-site accidents or injuries to ensure resolution in a timely manner.
• Plans and evaluates health education programs. Establishes, maintains and reviews nursing record keeping systems to ensure confidentiality and adherence to legal requirements.
• Conducts in-service education to ensure standardized application of policy and quality of nursing care. Develops medical directives in collaboration with upper management to ensure safety and hygiene of staff and patients.

What we're looking for

• Bachelor’s degree or equivalent work experience or combination of education and experience
• Minimum of two years Medicaid experience or other health care experience preferred
• Active RN or LPN license in the United States
• No license restrictions for applicable work
• Physically located in the United States

What you should expect in this role

This position will work daily (Monday through Friday) in an office in Topeka, Kansas.