Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Mentors and trains new team members. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. This position also trains and mentors new team members as well as assesses services for Sendero members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Utilizes clinical skills to review and monitor members’ utilization of health care services with the goal of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination of discharge planning needs. Obtains the information necessary to assess a member’s clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. Evaluates the options and services required to meet the member’s health needs, in support and collaboration with disease management interventions. Performs prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests.
This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a Central Health office in Austin, Texas. Remote work not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without
accommodations)
- Provides concurrent review and prior authorizations (as needed) according to policy.
- Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.
- Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Monitors level and quality of care for members.
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Monitors level and quality of care for members.
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Assist with establishing initial care plans and in the coordination of care through the health care continuum.
- Collect pertinent documentation and conduct medical services review applying appropriate criteria, including national standardized criteria and local plan rules and guidelines.
- Perform discharge planning activities in coordination with facility or provider case manager.
- Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan
- Consult with a Medical Director as appropriate for all requests requiring MD approval or not meeting criteria forapproval.
- Make referrals as indicated to other care management programs.
- Maintain open communication flow with to other care management staff to facilitate smooth transition and follow-up as member is transferred from one level of care and/or service to another.
- Collaborate with the Disease Management, Quality Management, and Utilization Management departments in the development of protocols and guidelines designed to standardize care practice and delivery.
- Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities.
- Perform other related tasks as assigned by supervisor or manager.
- Assist with leadership responsibility in collaboration with the HCS Leadership as required.
- Provides training and mentoring to HCS staff as appropriate.
- Maintains department productivity and quality measures
- Attends regular staff meetings.
- Provides assessment, training and mentoring of team members in a lead capacity.
- Completes assigned work plan objectives and projects on a timely basis.
- Maintains professional relationships with provider community and internal and external customers.
- Conducts self in a professional manner at all times.
- Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
- Complies with required workplace safety standards.
- Actively participates with the process of addressing and/or resolving appeals/fair hearings of medical necessitydenials.
- Participates in identifying and executing efficient processes.
- Assists with analysis of medical care, pharmaceutical cost and utilization management identify and anticipateutilization.
- Identify and report Sendero members experiencing complex, acute/chronic medical and/or behavioral illnesses, conditions or catastrophic injuries that may benefit from case management support.
- Provides training and mentoring to HCS staff as appropriate.
- Maintains department productivity and quality measures.
- Attends regular staff meetings.
- Completes assigned work plan objectives and projects on a timely basis.
Knowledge/Skills/Abilities
- Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management.
- Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities
including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and
preventive health guidelines.
- Demonstrated ability to lead, communicate, problem solve, and work effectively with people.
- Excellent organizational skill with the ability to manage multiple priorities.
- Work independently and handle multiple projectssimultaneously.
- Knowledge of applicable state, and federal regulations.
- In depth knowledge of Interqual and other references for length of stay and medical necessitydeterminations.
- Subject matter expert with NCQA requirements.
- Ability to take initiative and see tasks to completion.
- Computer Literate (Microsoft Office Products).
- Computer Literate (Microsoft Office Products).
- Excellent verbal and written communication skills.
- Ability to abide by Sendero’s policies.
- Ability to maintain attendance to support required quality and quantity of work.
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
- Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members,
providers and customers.
MINIMUM EDUCATION Completion of an accredited Registered Nursing (RN) program
MINIMUM EXPERIENCE (1-2) One to two years of clinical practice and (2-3) two to three years managed care
experience with utilization management and/or case management
REQUIRED CERTIFICATIONS/LICENSURE Holds and maintains these certifications as a professional. Lapsing/expiration of these
certifications/licensure will result in suspension of work
- Active, unrestricted State Registered Nursing license in good standing
PREFERRED EDUCATION Bachelor’s degree in nursing or health related field.
PREFERRED EXPERIENCE Managed care experience
PREFERRED CERTIFICATIONS/LICENSURE Case Management Certification (CCM), Utilization Management
Certification (CPHM) or other healthcare certification