Utilization Management Professional
Richmond, VA 23233
- Under general supervision, 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.
- 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 policies and 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.
- ** Must have 2 years Utilization post degree clinical experience.
- License: RN (State and/or Compact State License) Care Management, or LPN, or LCSW or LPC.
For more infomation on this position, please contact our office at 877-782-3334.