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Utilization Management Professional
Ref No.: 18-15461
Location: Brooklyn, New York
Utilization Management Professional (Healthcare)
Brooklyn, NY
3+ month contract
 
Description:
  • Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
  • Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information.
  • Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
  • Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
 
Essential functions:
  • Develops and manages new enrollee transitions and those involving a change in provider relationships.
  • Develops and implements transition plans, as indicated, to ensure continuity of care.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
  • Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
  • As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
  • In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
  • Collaborates with the Care Coordination Team to implement support for transitions in care.
  • Facilitates timely sharing of enrollees, clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
  • Assures that case documentation for each decision is complete, including related correspondence.
  • Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
  • Maintains an active work load in accordance with performance standards.
  • Works with community agencies as appropriate.
  • Participates in network development including identification and recruitment of quality providers as needed.
  • Advocates for the enrollee to ensure health care needs are met.
  • Interacts with providers in a professional, respectful manner.
  • Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.
 
Requirements/Certifications:
  • 3 years’ experience post degree in a clinical setting.
  • Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
  • Utilization Review
 
Preferred:
  • Managed Long Term Care Not Behavioral Health
  • Able to demonstrate the ability to quickly develop an alliance with providers via telephone.
  • On call coverage of Nurse Line as requested or required of position.
  • Ability to use computer systems.
  • Good organization, time management and verbal and written communication skills.
  • Knowledge of utilization management procedures, Managed long term care.
  • Medicare and Medicaid benefits, community resources and providers.
  • Knowledge and experience in diverse patient care settings including inpatient care.
  • Ability to function independently and as a team member.
 
Additional skills:
  • Knowledge of ICD and DSM IV coding or most current edition.
  • Ability to analyze specific utilization problems and creatively plan and implement solutions.
 
Licensing:
  • RN or LPN with New York state license must have Associates to go with.