Position Is Not Remote

Position Purposes:Evaluates and approves requested services using organizational policies or MCG® screening criteria.

Responsibilities:

Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests.
Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria
Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with health plan’s policy, criteria guidelines, and goals
Clearly and succinctly documents necessary and/or required information in Utilization Management system
Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times
Uses clinical subject matter expertise, as well as knowledge of the interconnection between Utilization Management, claims, and regulatory requirements to respond to complex and/or escalated inquiries
Identifies members who could benefit from care management and refers to the appropriate care manager
Utilizes critical thinking skills to identify process issues and problems andrecommend and/or implement solutions
May identify workflow and systems improvements to enhance Utilization Management’s ability to monitor, document and improve key department performance indicators
Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness
Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards
Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization
Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness
Uses Utilization Management system platform with proficiency

Qualifications:

Bachelor’s degree in Nursing or NursingSchool Degree with equivalent relevant work experience
Minimum3 yearsof related experience in an acute care or health insurance environment
Minimum 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning

Knowledge/Skills/Abilities:

Bi-lingual preferred
Ability to create positive work environment and dynamic with individuals and groups
Ability to take action in solving problems exhibiting sound judgement
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts
Demonstratesstrong organization and time management skills
Able to work in a fast-paced environment; ability to multi-task
Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications
Strong analytical and clinical problem-solving skills
Ability to work OT during peak periods

ote: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

Powered by JazzHR

WhrqaCkkd7

Doctors HealthCare Plans, Inc.

New Jobs

Medical Management Coordinator RN