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Job Description Summary :
Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits.
Conducts pre-service, concurrent and / or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars.
Schedules time effectively; works with minimal supervision; handles multiple projects simultaneously; prioritizes work appropriately to streamline process and identifies opportunities for quality or process improvement; Uses critical thinking skills, problem solving and organizational skills; works as a team member while maintaining a positive attitude
Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as well as federal and state mandates; Maintains confidentiality of all PHI in compliance with state and federal laws; Reads, understands and follows medical policy and all corporate, divisional and departmental policies and procedures.
Reviews provider and/or member submitted medical information to determine pre-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure utilizing professional knowledge, medical literature, medical records, certificate guidelines, medical policy, approved clinical guidelines, and several complex and varied computer application software systems. Refers cases that do not meet criteria to the Medical Director with an appropriate clinical analysis, summaries and recommendations. Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a safe plan
Recognizes, documents and reports inappropriate billing patterns or utilization trends of professional and institutional providers to the appropriate business owner.
Communicates effectively with team members, other departments within the organization, management, members &/or providers; assess and educate members &/or providers on a proactive basis; utilizes internal, community and other healthcare resources as well as clinical knowledge to maximize outcomes, as well as referrals to case management, disease management, community health specialist, etc.
Contributes to reaching or exceeding departmental, divisional and corporate goals; knowledgeable of business goals, progress toward accomplishment of goals and works collaboratively with peers to meet or exceed annual departmental targets; analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction
3+ years full-time direct patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics.
Proven experience effectively presenting information and responding to questions from groups of managers, clients, customers, and the general public.
Proven experience in problem definition, data collection to establish facts, and drawing valid conclusions to solve practical problems while working with a variety of concrete variables in situations where only limited standardization and direction exists.
RN license in Missouri and/or Kansas
Bachelor’s degree in nursing preferred.
1+ year(s) of utilization review, disease management, and/or case management experience.
Knowledge of ICD, CPT and HCPCS coding.
Knowledge of URAC and NCQA guidelines and state and federal regulations
Intermediate keyboarding skills.
Intermediate knowledge of FACETS.
Intermediate knowledge of Clinical Guidelines.