Job Description

Responsibilities
• Process prospective, concurrent, retrospective Utilization Management (UM) medical requests
• Ensure compliance with Utilization Management determinations, retro reviews, and case management programs according to SPD, time frames, clinical policies, and operational workflows
• Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently
• Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests
• Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors
• Authorize vendor services based on skilled need and or medical necessity applying relevant
• Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines
• Troubleshoot and intervene with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
• Work closely with medical advisors and management team for escalated complex UM requests
• Conduct internet research to retrieve data for complex cases
• Serve as a liaison with other departments and ensure effective communication with all areas of the Fund
• Establishes proactive approach to problem solving
• Comply with UM productivity standards, track, and report regularly
• Maintain appropriate documentation of all services in keeping with all confidentiality and HIPPA regulations
• Perform special projects and assignments as directed by management

Qualifications
• Associate’s degree and Valid Licensed Practical Nurse (LPN) required
• Minimum three (3) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) experience plus minimum two (2) years of Utilization Management experience required.
• BSN and Certification in Case Management a plus
• Working experience utilizing Milliman Care Guidelines
• Strong clinical skills and background.
• Intermediate level Microsoft Word, Excel, and Outlook.
• Internet research for investigating and retrieving pertinent data for complex inquiries.
• Effective time management skills.
• Must have the ability to exercise judgment and discretion in establishing and maintaining good work habits and relationships, maintaining the confidentiality of the position in all dealings
• Ability to work in fast-paced high volume work environment, maintain professional manner and presentation, multi-task, establish priorities, delegate, meet deadlines and follow through on assignments