This position is responsible for promoting the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prospective authorization referral requests.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Responsible for implementing and coordinating all utilization management functions relating to the pre-authorization of select outpatient testing, surgery, and elective inpatient admissions.
- Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence based standards.
- Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services and out of network providers.
- As needed, they will forward requests to the Medical Director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.
- Utilizes designated criteria along with clinical knowledge to make authorization decisions and assist with review determinations.
- Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Ensures accurate coding using CPT-4 and ICD-9 codes and documents all information accurately.
- Applies appropriate benefits information to determine if requested services are a covered benefit.
- Applies medical knowledge and experience to authorize pre-service requests.
- Identifies cases appropriate for case management and makes timely transition to the Care Management department.
- Identifies potential quality of care issues and refers to the Quality Department.
- Meets service standards for decision turn-around times and written correspondence.
- Requires a high school diploma or GED.
- Requires four (4) years’ utilization management experience. Must possess a strong understanding of Managed Care including referral requirements.
- Requires a valid, unrestricted state nursing license (RN or LVN).
- Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system.
- High energy; demonstrates an ability to function in a creative, entrepreneurial environment and think outside the box.
- Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
- Knowledge of ambulatory healthcare delivery and management.
- Able to demonstrate strong knowledge of the prospective authorization process and workflow.
- Intermediate computer literacy (MS Office) and typing skills are necessary.
- Strong interpersonal and decision-making skills; must be able to introduce new ideas, processes, and tools to improve department performance.