Communication: Serves as a liaison facilitating a collaborate process between multiple internal functional areas, clinical leadership, primary physicians, patients and Medical Director to assist with escalated cases that requires input from multiple areas with the enterprise, providers, facilities and vendors.
Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
Data Analysis: Integrates data from multiple data sources or functional areas, ensures data accuracy and integrity, and updates data as needed to develop models to be used for decision making and initiatives
Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
Other duties as assigned.
Participant: Serves on various committees and project teams related to policy changes, system enhancements, process improvement initiatives, etc.
Process Improvement: Monitors and evaluates data and processes to ensure accuracy and identify changes to increase efficiency and effectiveness.
Researcher: Serves as a resource to Medical Director(s) and Care Management team providing analysis, reporting and research on medical conditions, medical terminology, medications, lab work, medical records, healthcare processes, coverage policies, plan guidelines, and/or health/wellness.
Certifications
Security Requirements
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.
Requirements
EDUCATION
High school diploma or equivalent required.
LICENSING/CERTIFICATION
Licensed Practical Nurse (LPN) with current active state license in the state(s) where job duties are performed required.
Minimum four (4) years' clinical nursing experience, to include a broad background in various facets of nursing.
Knowledge of HCPCS/CPT/Revenue codes and general coding principles.
Knowledge of claims processing rules/logic.
Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.
Minimum two (2) years' utilization review, medical policy, and/or case management experience required. Previous experience in appeals and/or grievances process preferred.
ESSENTIAL SKILLS & ABILITIES
Excellent Oral & Written Communication
Detail-Oriented
Strong analytical, critical thinking, organizational and time management skills
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, Outlook, and PowerPoint, including the ability to navigate multiple systems and keyboarding.
Ability to make sound judgments and decisions based on facts and guidelines.
Ability to build collaborative relationships.
Ability to work independently with little supervision.
Ability to interpret complex documentation.
Analyze Information
Consultative Approach
Critical Thinking
Decision Making
Documentations
Evaluating Information
External Collaboration
Interpersonal Communication
Monitor Processes, Materials, or Surroundings
Oral Communications
Organizing
Process Information
Researching
Resources Administration
Results Interpretation
Time Management
Benefits
Health insuranceVision insuranceRemote work options
Additional Information
To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here .
Job Summary
LPN Clinical Research Coordinator organizes, analyzes, researches and manages complex programs, medical data and activities, which integrates multiple functional areas including case management, utilization management, disease management, health education, maternal child care management programs, and/or closure of gaps in care.
Arkbluecross · Arkansas Remote