1199seiubenefits
Responsibilities
Process prospective, concurrent, retrospective Utilization Management (UM) medical requests
Ensure compliance with Utilization Management determinations, retro reviews, and case management programs according to SPD, time frames, clinical policies, and operational workflows
Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently
Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests
Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors
Authorize vendor services based on skilled need and or medical necessity applying relevant
Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines
Troubleshoot and intervene with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
Work closely with medical advisors and management team for escalated complex UM requests
Conduct internet research to retrieve data for complex cases
Serve as a liaison with other departments and ensure effective communication with all areas of the Fund
Establishes proactive approach to problem solving
Comply with UM productivity standards, track, and report regularly
Maintain appropriate documentation of all services in keeping with all confidentiality and HIPPA regulations
Perform special projects and assignments as directed by management
Qualifications
Associate’s degree and Valid Licensed Practical Nurse (LPN) required
Minimum three (3) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) experience plus minimum two (2) years of Utilization Management experience required.
BSN and Certification in Case Management a plus
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Process prospective, concurrent, retrospective Utilization Management (UM) medical requests
Ensure compliance with Utilization Management determinations, retro reviews, and case management programs according to SPD, time frames, clinical policies, and operational workflows
Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently
Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests
Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors
Authorize vendor services based on skilled need and or medical necessity applying relevant
Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines
Troubleshoot and intervene with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
Work closely with medical advisors and management team for escalated complex UM requests
Conduct internet research to retrieve data for complex cases
Serve as a liaison with other departments and ensure effective communication with all areas of the Fund
Establishes proactive approach to problem solving
Comply with UM productivity standards, track, and report regularly
Maintain appropriate documentation of all services in keeping with all confidentiality and HIPPA regulations
Perform special projects and assignments as directed by management
Qualifications
Associate’s degree and Valid Licensed Practical Nurse (LPN) required
Minimum three (3) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) experience plus minimum two (2) years of Utilization Management experience required.
BSN and Certification in Case Management a plus
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