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 contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

 
How you will do it

• 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, Client Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all Client 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.

What we look for

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable

• accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education Level: Bachelor's Degree

• Education Details: Nursing

• Experience: 5 years Clinical nursing experience

• 2 years Care Management

In Lieu of Education

• In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

• Preferred Qualifications

• Working knowledge of managed care and health delivery systems.

• Thorough knowledge of Client clinical guidelines, medical policies and accreditation and regulatory standards

• Working knowledge of Client 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

• The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

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