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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.
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 appropriate 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 implementation of specific strategies that improve the quality and outcomes of care.
Performs other duties as assigned.
Required A High School or GED
Required 2 years of experience in Nursing
Preferred 1 year of experience in Performing utilization reviews
Preferred Other Experience performing UM in a managed care setting
Intermediate Ability to communicate and make recommendations to upper management
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 Knowledge of healthcare delivery
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Other Strong decision-making and administrative skills
Licenses and Certifications: A license in one of the following is required:
Required Licensed Practical Nurse (LPN)
Required Beginner Microsoft Excel
Required Beginner Microsoft Word
Required Beginner Microsoft Outlook
Required Beginner Healthcare Management Systems (Generic)