Detroit, MI 48226
- This position ensures that authorization requests and provider inquiries are handled appropriately within established timeframes, and established guidelines and protocol are utilized for clinical decision-making.
- Functions collaboratively with the members of the Utilization Management team, and specifically with the review nurses, case managers and Medical Directors to ensure for timely disposition of inpatient authorization requests and discharge planning activities.
- Oversee the queue workload needs on a concurrent basis including the inpatient authorization queues and the inpatient fax queues in the UM department to concurrently prioritize self-assignment for greatest impact on department function.
- Support orientation program for UM staff by acting as primary mentor for review nurses, UM specialists and physician reviewers.
- In conjunction with medical leadership, act as resource for criteria and benefit interpretation including the correct and consistent application of the InterQual criteria on the appropriate topics, consistent application of procedural practices established by client.
- Supply ongoing training and education to the staff through one-on-one and classroom settings regarding InterQual, National Committee for Quality Assurance (NCQA), URAC or general accreditation, MDCH and other necessary job-related skills.
- Collaborate with the Disease Management, Quality Improvement, and Utilization Management departments in the development of protocols and guidelines designed to standardize care practice and care delivery.
- Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities.
- Receive and review all emergent inpatient admission and observation notifications.
- Review clinical data against established protocols/guidelines and within established timeframes to determine disposition of admission authorization requests.
- Complete authorization process in system for approved authorizations and contact hospital reviewers with decision, days authorized and corporate authorization number.
- Contact hospital reviewers where additional information is necessary to make a decision.
- Consult with Medical Director as appropriate for all requests that do not meet criteria for admission and inform hospital reviewers of the Medical Director's decisions
- Create and fax/mail denial letters to hospitals as required and within established timeframes.
- Receive and process clinical updates for continued stay.
- Initiate and follow through on all aspects of discharge planning, including, but not limited to, identification of needs, coordination of care and transitioning to alternate levels of care.
- Collaborate with inpatient reviewers and other staff for discharge planning needs or transfer to alternative level of care.
- Performs post discharge calls to members post inpatient, SNF and acute rehabilitation services in accordance with department guidelines.
- Assists to coordinate follow-up appointments, home health care services, pharmacy services, and refer to care coordination or complex case management and/or community resources as indicated.
- Monitor documentation, follow up calls to members are made in a timely manner according to follow date set and acuity level.
- Coordinates activities with other medical management departments as needed, including making referrals to Case Management and Behavioral Health.
- Communicate with providers and members on an ongoing basis to facilitate compliance and competency with established programs and guidelines to assist with decrease ER visits.
For more information on this position, please contact our office at 877-782-3334.