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. Works collaboratively with providers and facilities to determine, coordinate and authorize post-acute care services and provide referrals to clinical and social support services, including but not limited to, case/disease management, other providers within the plan's network and with community based resources.
DEPARTMENT: Health Services-Utilization Management
REPORTS TO: Supervisor, Clinical Care
- 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.
- Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and/or hospitals, to share information and collaboratively establish acute and post-acute treatment plans for hospitalized members.
- 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.
- Documents clinical updates, authorizations and referrals in the health plan medical management system adhering to health plan documentation standards.
- 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.
- Nurse will be based out of home or office after successfully completing training and meeting specific metrics, with possible travel required to assigned hospitals and facilities. Valid driver's license, without restrictions, is required.
- Required a High School or GED
- Required a Registered Nurse degree
- Preferred a Bachelor's Degree in nursing
- 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 care management experience in a managed health care setting
Licenses and Certifications:
- Intermediate 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
- Required Licensed Registered Nurse (RN), no restrictions
- Required intermediate Microsoft Excel, Word and Outlook
- Required intermediate Healthcare Management Systems (Generic) Ability to use health services management systems