Specialized Recruiting. Temporary Staffing. Managed Services. 800 876 2314


OrthoCare Manager – (RN or LPN)

Employment Type Permanent
Field of Work Clinical/Medical

 

Position Summary

The OrthoCare Manager, Musculoskeletal reports directly to either the Manager or Director of Medical Management depending upon their job location and program that they are managing. The incumbent,has the administrative responsibility for the overall direction, utilization, supervision, instruction, and examination of the medical care of the member assigned to them.

Position Responsibilities

  • Review of Musculoskeletal (MSK) care evaluations and progress reports to determine if medical necessity has been met or refer to Medical Directors when clinical information does not meet clinical criteria for either initial or continued authorization.
  • Review documentation submitted to support the medical necessity of the request.
  • Ensure clinical information submitted for peer review and entered into patient’s electronic record is the most accurate and up to date.
  • Interacts with the physician to ensure the most appropriate and highest quality of care is recommended.
  • Prepare and file miscellaneous reports, outcome data, and records needed by Company.
  • Collaborate with Contract Assistants working on their team to ensure that responses to authorization requests are responded to within Regulatory timeframes.
  • Maintain contact and communication with insurance companies to apprise them of case activity, case direction or receive authorization services.
  • Maintain contact with all parties involved in case management for the client.
  • Act as clinical resource/educator for the multi-disciplinary health care team on an ongoing basis in order to maximize quality of patient care as well as effectively manage length of stay and utilization resources as appropriate.
  • Adhere to all documentation and performance guidelines.
  • Perform other duties as assigned.

Position Requirements

  • BSN preferred; Current and active unrestricted State License/Registered or Certified in Nursing
  • A minimum of three (3) years’ experience in an acute care related setting, along with at least one (1) year of direct experience in a position doing orthopedic or musculoskeletal case / utilization management or pre-authorization related work; with prior experience in a Managed Care environment highly preferred.
  • Knowledge of the clinical criteria (e.g. (MCG), CMS, InterQual, Milliman, etc.) is required.
  • Proficiency in operating multiple business and clinical computer applications is needed.
  • Excellent interpersonal, verbal and written skills required.
  • Excellent verbal and written communications skills

Machine, Office Equipment & Software:

  • MS Office (MS Word, Excel, and Power Point)
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