Spec, Utilization Management

Job Description:

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation and regulatory requirements to contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

ESSENTIAL FUNCTIONS

• Abstractor Primary functions:
  • 50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
  • 30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
  • 20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Qualifications

• Education Level: Bachelor's Degree
• Education Details: Nursing
• Experience: 5 years Clinical nursing experience, 2 years Care Management
• Clinical Utilization Management expertise, regulatory compliance knowledge, experience in Guiding care platform

Licenses/Certifications

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or
• LPN - Licensed Practical Nurse - State Licensure
• CNS-Clinical Nurse Specialist Pref

Preferred Qualifications

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of clinical guidelines, medical policies and accreditation and regulatory standards
• Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Knowledge, Skills and Abilities (KSAs)

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
• Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient
• Must be able to work effectively with large amounts of confidential member data and PHI, Expert
• Must be able to prioritize workload during heavy workload periods, Proficient
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.