Position Is Not Remote
Position Purposes: Evaluates and approves requested services using organizational policies or MCG® screening criteria.
Responsibilities:
- Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests.
- Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
- Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with health plan’s policy, criteria guidelines, and goals.
- Clearly and succinctly documents necessary and/or required information in Utilization Management system.
- Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times.
- Uses clinical subject matter expertise, as well as knowledge of the interconnection between Utilization Management, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
- Identifies members who could benefit from care management and refers to the appropriate care manager.
- Utilizes critical thinking skills to identify process issues and problems and recommend and/or implement solutions.
- May identify workflow and systems improvements to enhance Utilization Management’s ability to monitor, document and improve key department performance indicators.
- Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness.
- Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards.
- Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization.
- Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness.
- Uses Utilization Management system platform with proficiency.
Qualifications:
- Bachelor’s degree in Nursing or Nursing School Degree with equivalent relevant work experience.
- Minimum 3 years of related experience in an acute care or health insurance environment.
- Minimum 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.
Knowledge/Skills/Abilities:
- Bi-lingual preferred.
- Ability to create positive work environment and dynamic with individuals and groups.
- Ability to take action in solving problems exhibiting sound judgement.
- Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
- Demonstrates strong organization and time management skills.
- Able to work in a fast-paced environment; ability to multi-task.
- Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications.
- Strong analytical and clinical problem-solving skills.
- Ability to work OT during peak periods.
ote: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
•
Last updated on Feb 26, 2025