Oversees the utilization management activities by evaluating 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.
Reports To: Sr., Medical Director
Department: Health Services
Position Location: Atlanta, GA 30346
Additional Responsibilities:Candidate Education:
- Reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria.
- Ensures that services provided to eligible members are within benefit plan, and appropriate contracted providers are being utilized.
- Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Identifies apporpriate clinical settings for services being requested.
- Identifies and refers cases appropriate for case management.
- Identifies potential quality of care issues and refers to Quality Department.
- Ability to follow and apply all necessary regulatory requirements for assigned market.
- Determines appropriate utilization management of services requested.
- Assists with implementation of healthcare initiatives in market.
- Assists in the implementation of specific strategies that improve the quality and outcomes of care.
- Acts as a subject matter expert within the team.
- Handles escalated issues at managements request.
- Acts as a team educator on new processes and/or policies.
- Performs and represents department and clinical duties at the request of management.
- Performs other duties as assigned.
- Required A High School or GED
- Required 4 years of experience in a acute clinical/surgical position(s), current experience 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
Licenses and Certifications:
- Intermediate Ability to communicate and make recommendations to upper management Ability to work independently, handle multiple assignments and prioritize workload
- Intermediate Ability to work independently
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Ability to lead/manage others
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Other Strong knowledge of practice guideline
- Intermediate Other Strong decision-making and administrative skills
A license in one of the following is required:
- Required Licensed Practical Nurse (LPN)
- Required Other RN required in the state of Georgia only
- Required Beginner Microsoft Excel Proficient in Microsoft Office including Excel, Word and Outlook Express
- Required Beginner Microsoft Word
- Required Beginner Microsoft Outlook
- Required Beginner Healthcare Management Systems (Generic)