Job Description

Responsibilities
• Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach
• Performs medical necessity review that includes concurrent, prospective, retrospective reviews and 1st level appeals, to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and vendor contracts.
• Apply Milliman Care Guidelines, internal Policies and Reference Guides to determine appropriateness of services/equipment that require Prior Authorization
• Maintain accurate records of all patient/provider/vendor related interactions in designated medical management system
• Apply clinical guidelines, provide recommendations and discuss cases with Medical Consultants
• Meet timelines and quality standards related to Utilization Management
• Maintain and submit reports and logs on reviewed activities as outlined by the UM program operational procedures,
• Identify and participate in quality improvement activities as it relates to internal programs, processes studies and projects
• Authorize vendor services using clinically proven criteria to make consistent care decisions
• Maintain compliance with all state mandated regulations
• Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
• Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations
• Perform additional duties and projects as assigned by management

Qualifications
• Bachelor’s degree Valid New York State Registered Nurse (RN) required
• Minimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Utilization Management experience required
• BSN and Certification in Case Management a plus
• Proficient in application and use of industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding
• Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
• Computer and organizational skills required, ability to manage competing priorities, multi-task with results-oriented outcomes and work in a fast paced environment. Intermediate skills of Microsoft Office systems preferred.