Reporting to the Outpatient Lead Clinician, the UM Outpatient Licensed Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.
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Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required
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Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
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Promote improved quality of care and/or life
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Prevent hospitalization when possible and appropriate
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Provide for continuity of care
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Ensure appropriate levels of care are received by members
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Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business
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Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers
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Identify complex authorization requests and appropriately refer to Case Management personnel
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Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests
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Work effectively with all other sub team members within Outpatient UM
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Maintain prompt and open communication with Denial team to meet tight turnaround time (usually with 24hours of initial request)
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Communicate with Health Plan Liaisons if a precertification request requires health plan review, ensuring review is completed in compliance with timeliness standards
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Outreach to Provider Network Operations team to address provider related referral insufficiencies
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Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources
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Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.
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Maintain knowledge of UM policy and procedures
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Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians
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Attend all mandatory onsite and virtual meetings to ensure alignment with team goals, project updates, and organizational communication.
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Current California RN or LVN license
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2+ years of experience in utilization management preferred
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Proficiency with Microsoft Office Programs; primarily Word and Excel
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EZ-CAP® knowledge a plus
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Excellent relationship management skills with the ability to communicate effectively with all stakeholders
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Strong organizational, task prioritization, and delegation skills
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Ability to collaborate successfully with all levels of the organization
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LVN $36-$39/hr; RN $42-$48/hr
