Working knowledge of managed care and health delivery systems
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or LPN - Licensed Practical Nurse - State Licensure
Requirements:
Perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage
Analyze clinical information, contracts, mandates, and guidelines to determine appropriateness and authorization of clinical services
Conduct research and analysis of pertinent diseases, treatments and technologies to support decisions
Make appropriate referrals and assist members and providers for alternative settings for care
Job description
Our client, a Health Insurance company, is looking for a Spec, Utilization Management for their Remote location.
Responsibilities:
Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage.
Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.
50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, client Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all client lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities.
Follows member contracts to assist with benefit determination.
20% Makes appropriate referrals and contacts as appropriate.
Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.
Requirements:
Experience: 5 years Clinical nursing experience
2 years Care Management
In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Working knowledge of managed care and health delivery systems.
Thorough knowledge of client clinical guidelines, medical policies and accreditation and regulatory standards
Working knowledge of client IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient
Must be able to work effectively with large amounts of confidential member data and PHI, Expert
Must be able to prioritize workload during heavy workload periods, Proficient
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient
Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or
LPN - Licensed Practical Nurse - State Licensure
CNS-Clinical Nurse Specialist Pref
Additional Skills: Clinical UM expertise, regulatory compliance knowledge, experience in Guiding care platform
