Oversees the utilization management activities of outpatient review staff 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. Director UM Strategy
Department: Population Health Solutions
Location: Tampa, FL
Additional Responsibilities: Intermediate Knowledge of healthcare delivery Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding Intermediate Demonstrated problem solving skills Licenses and Certifications:
- Ensures that staff reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria.
- Monitors staff work product to ensure that services provided to eligible members are within benefit plan, and appropriate contracted providers are being utilized.
- Ensures that staff initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Ensures that staff identify appropriate clinical settings for services being requested.
- Ensures that staff identify and refer cases appropriate for case management.
- Ensures that staff identify potential quality of care issues and refers to Quality Department.
- Determines appropriate utilization management of services requested and ensures that staff are able to do same.
- Assists with implementation of health care 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 management's request.
- Acts as a team educator on new processes and/or policies.
- Performs and represents department and clinical duties at the request of management.
- Reviews and collects data to identify patterns and trends for member service utilization.
- Trains and mentors staff to ensure compliance with departmental regulations, policies and procedures.
- Provides direct supervision to outpatient care staff.
- Performs other duties as assigned.
A license in one of the following is required:
- Required Licensed Practical Nurse (LPN)
- Required Beginner Microsoft Excel Proficient in Microsoft Office including Excel, Word and Outlook Express
- Required Beginner Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)