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Oversees utilization management activities by assessing the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan.
Telephonically reviews medical information in order to determine the medical necessity of continued stay according to review standards. Determines whether treatments are consistent with member's diagnosis and appropriate level of care.
Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
Determines medical necessity and length of stay based on the consistent application of CMS criteria, Interqual criteria, and Clinical Coverage Guidelines and communicates with Medical Directors for those reviews that fall outside of approvals.
Assesses and coordinates simple discharge planning (short-term rehabilitation, homecare etc) with physicians, caregivers and ancillary providers to support the member's continuity of care needs.
Interacts with facility discharge planners/utilization management team to coordinate medical treatment plan, and identifies opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care.
Identifies members at high risk for complicated medical treatment plans, and/or repeat admissions potential and refers them to the appropriate case and disease management teams.
Coordinates authorization and/or delivery of post-acute care services, including, but not limited to referrals to case and disease management, home health, medical equipment, skilled nursing facilities and other community based services.
Identifies quality of care issues, and reports to appropriate health plan Quality department representative. Ability to follow and apply all necessary regulatory requirements for assigned market.
Oversees the appropriate utilization management of services requested.
Assists with implementation of healthcare initiatives in market.
Assists in implementation of specific strategies that improve the quality and outcomes of care in market.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in a related field
Required 2 years of experience in a clinical setting with general nursing exposure in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
Preferred Other Care management experience in a managed health care setting
Intermediate Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
Intermediate Ability to multi-task
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Ability to create, review and interpret treatment plans
Intermediate Demonstrated problem solving skills
Intermediate Knowledge of healthcare delivery
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to effectively present information and respond to questions from peers and management
Licenses and Certifications: A license in one of the following is required:
Required Licensed Practical Nurse (LPN)
Required Beginner Microsoft Excel Proficient in Microsoft Office such as Excel, Word and Outlook
Required Beginner Microsoft Word
Required Beginner Microsoft Outlook
Required Beginner Healthcare Management Systems (Generic) Ability to use health services management systems