Utilization Management Reviewer (RN) I/II/III - SN LTSS at Excellus Health Plan Inc. Job Listing at DirectEmployers in Rochester, NY (Job ID 3984625-2024-08-20)

Description

Job Description:

Summary:

This position is responsible for coordinating, integrating, and monitoring the utilization of physical health (PH) medical and healthcare services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs.

Participates in rotating on-call schedule, as required, to meet departmental time frames.

Per department needs, may be responsible for additional hours.

Essential Responsibilities/Accountabilities:

Level I:

• Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members' medical health conditions, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates. May perform clinical review telephonically, electronically, or on-site, depending on customer and departmental needs.
• Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical knowledge, members' specific health plan benefits, and efficient care delivery processes. Ensures compliance with corporate and departmental policy and procedure, identifies and refers potential quality of care and utilization issues to Medical Director.
• Utilizes appropriate communication techniques with members and providers to obtain clinical information, assesses medical necessity of services, advocating for members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care.
• Collaborates with hospital, home care, care management, and other providers effectively to ensure that clinical needs are met and that there are no gaps in care.
• Acts as a resource and liaison to the provider community in conjunction with Provider Relations, explaining processes for accessing Health Plan to perform medical review, obtains case or disease management support, or otherwise interacts with Health Plan programs and services.
• Makes accurate and consistent interpretation of required clinical criteria, medical policy, contract benefits, and State and Federal Mandates.
• May be responsible for pricing, coding, researching claims to ensure accurate application of contract benefits and Corporate Medical Policies.
• Accountable for meeting departmental guidelines for timeliness, production and metrics and meeting requirements established for audits to ensure adherence to regulatory and departmental policy/procedures.
• Maintains compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.
• Assists with training and special projects, as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

• Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
• Mentors staff and assists with coaching, as necessary.
• Provides consistent positive results on audits.
• Works independently in coordinating and collaborating with members and providers, resulting in improving member and com

  Compensation Information:
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  Starting At: 0.0
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