Summary:

Utilization Management Reviewer (UR) is the critical evaluation of health care services provided to members using an integrated approach to determine the necessity and appropriateness of those services, with the purpose of controlling costs and monitoring quality of care. The Utilization Management Reviewer will play a key role in conducting these reviews and communicating the results of these reviews to all involved parties. The UM reviewer will facilitate the timely access to necessary, appropriate, high-quality services for members.

Essential Job Functions:

• Conduct retrospective (post-service), concurrent, and prospective (pre-service) reviews of health care services to determine if these services meet plan covered status guidelines, and to determine the appropriateness and medical necessity of those services

• Compile and review the necessary documents and clinical records to effectively and accurately conduct the reviews

• Collaborate with members of the interdisciplinary team to obtain current and accurate information, and where necessary, seek and acquire additional information as needed to assist with safe and appropriate health care decisions

• Collaborate with other members of the interdisciplinary team to reach consensus on determinations

• Will work cooperatively with providers of services to ensure members receive the right care, in the right place, at the right time

• Fully comply with all state and federal laws and internal policies to maintain the confidentiality of Protected Health Information (PHI) and financial information

• Identify suspected Quality of Care, risk, and utilization issues discovered during the reviews to the Quality Management Oversight Committee (QMOC)

• Comply with established time frames for conducting both urgent and non-urgent reviews

• Meet performance benchmarks for the timeliness of reviews and communicating decisions

• Adopt a thorough working knowledge of Medicaid and MLTC Rules and Regulations, clinical care guidelines, plan covered services, internal policies, and evidence-based nationally recognized medical necessity criteria such as InterQual® and MCG(Millman)®

• Conduct all reviews in harmony with these rules and regulations, guidelines, policies, and criteria

• Communicate the results of reviews, including denials for services, to all involved parties within established policy time frames, along with reasons for authorization or denial, supported by objective and unbiased criteria (see above)

• Comply with all UM Program guidelines

• Help develop workflows based on recognized best practice

• Provides information to the QMOC and Chief Medical Officer to assist in revising UR Standard Operating Procedures when needed to adapt to changes in laws or criteria, or in response to workflow process improvement activities

• Tracks statistics and trends, and reports to the QMOC/UM Committee

• Perform all other duties relevant to the position as assigned by supervisor.

• Acts as Subject Matter Expert in Utilization Review and medical necessity criteria

• Continually maintain clear, effective communication with team

• Collaborate with other iCircle departments

• Adhere to ethical, legal, accreditation, certification, and regulatory standards and guidelines.

• Demonstrate cultural competence by being respectful of and responsive to the health beliefs, practices, cultural and language needs of the member and his/her support system

• Perform all other duties relevant to the position as assigned by supervisor.

  Knowledge, Skills, and Abilities:

• Ability to work collaboratively and effectively with the interdisciplinary team members, iCircle members, families and providers.

• Ability to work independently and motivate others

• Ability to communicate effectively, both orally and in writing

• Excellent verbal and written communication skills, expressing self in a clear, concise and professional manner.

• Possess strong computer skills and efficiency using Microsoft Word and other applications

• Ability to efficiently and competently navigate electronic medical records

• Knowledge of Medicaid and Medicare regulations

  Education and Experience:

• Bachelor’s degree in Nursing

• State licensure as a Registered Nurse (RN)

• Minimum 2 years of prior experience in Utilization Management

  The listed salary range represents the organization's good faith and reasonable estimate of the range of possible compensation at the time of posting. The offered salary will be determined by: Applicant qualifications and experience, education, position specific licensing/training and departmental budgets.

  CDS Life Transitions is an Equal Opportunity Employer, and as such affirms the right of every person to participate in all aspects of employment without regard to gender, race, color, religion, national origin, ancestry, age, marital status, sexual orientation, pregnancy, disability, citizenship, military or veteran status, gender expression and/or identity, or any other status or characteristic protected by federal, state, or local law. CDS Life Transitions will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business. If you are interested in applying for an employment opportunity and feel you need a reasonable accommodation pursuant to the ADA, please contact us at 585-341-4600.