Utilization Management Professional
- The candidate will work an 8 hour shift that could start between the hours of 8am 10: 30am.
- Under general supervision by management, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
- Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria.
- Collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
- Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
- Caseload: 25-30 reviews per day.
- This position is 98% telephonic.
- There will be rounds with a Doctor for 15 mins every day.
- Develops and manages new enrollee transitions and those involving a change in provider relationships.
- Develops and implements transition plans, as indicated, to ensure continuity of care.
- Negotiates and documents single case agreements according to the company s procedures.
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
- Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
- As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
- In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
- Collaborates with the Care Coordination Team to implement support for transitions in care.
- Facilitates timely sharing of enrollees clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
- Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
- Assures that case documentation for each decision is complete, including related correspondence.
- Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
- Maintains an active work load in accordance with performance standards.
- Works with community agencies as appropriate.
- Participates in network development including identification and recruitment of quality providers as needed.
- Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
- Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.
Experience & Education:
- Master's Degree.
- MUST have BH experience.
- The manager is looking for 3 years of Inpatient Medical experience, 3 years of Utilization experience, Concurrent Review experience and HMO exp.
- Training will be 3 4 weeks long that will include Magellan Code of Conduct, Systems App and Shadowing.
- Credentialing Paperwork will be completed during training.
- LCSW, LCPC or RN.
- A Master s degree is required for ALL licenses EXCEPT for the RN.
- A Bachelor s degree is required for the RNs.
A-Line Staffing Solutions