Dept: Clinical Review
Will this position be required to work onsite for any reason at any time? No
SUMMARY
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
2. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards and CMS regulations.
3. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
4. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
5. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
6. Identify and document quality of care issues; resolve or route to appropriate area for resolution.
7. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
8. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
9. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
10. Other duties may be assigned based on designated department assignment.
EDUCATION AND EXPERIENCE
1. Bachelor's degree in nursing, allied health, business, or related field preferred.
2. Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
3. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
4. One (1) year health insurance plan experience or managed care environment preferred.
5. One (1) year of utilization management preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
1. Registered Nurse with current unrestricted Michigan Registered Nurse license required.
2. Certification in Case Management may be preferred based upon designated department assignment.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
1. Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
2. Working knowledge of current industry Microsoft Office Suite PC applications.
3. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
4. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
5. Knowledge of cost containment strategies, major health care payer policies and procedures, member benefits and community resources.
6. Knowledge of applicable accreditation standards, local, state and federal regulations.
7. Other related skills and/or abilities may be required to perform this job based upon designated department assignment.
ADDITIONAL INFORMATION
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.
APPENDIX:
Vendor Programs
1. Responsible for responding to client member level inquiries received from customer service, communicating the clinical information related to decisions our vendors make on our behalf for medical necessity.
2. Educate member services and members/providers on member benefits.
3. Assist with answering questions, supplying information and training on UM program (internally and externally).
4. Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations.
5. Evaluate clinical documentation to resolve member inquires as to UM decisions and appeals/grievances.
6. Review claims issues pertaining to UM program to ensure correct reimbursement for covered/and or approved services, and resolve, and/or devise solutions to mitigate any gaps identified.
7. Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services.
8. Work with cross functional teams to resolve issues/concerns/inquiries.
9. Compile and report data based on member and provider inquiries.
10. Registered Nurse with current unrestricted Michigan Registered Nurse license, Licensed Physical Therapist or Licensed Occupational Therapist required.
11. Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities.
