Role Description
Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits.
The candidate for this position must reside in the Kansas City metropolitan area.
• Conducts pre-service, concurrent and/or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars.
• Schedules time effectively; works with minimal supervision; handles multiple projects simultaneously; prioritizes work appropriately to streamline process and identifies opportunities for quality or process improvement.
• Uses critical thinking skills, problem solving and organizational skills; works as a team member while maintaining a positive attitude.
• Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as well as federal and state mandates.
• Maintains confidentiality of all PHI in compliance with state and federal laws.
• Reads, understands and follows medical policy and all corporate, divisional and departmental policies and procedures.
• Reviews provider and/or member submitted medical information to determine pre-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure.
• Refers cases that do not meet criteria to the Medical Director with an appropriate clinical analysis, summaries and recommendations.
• Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a safe plan.
• Recognizes, documents and reports inappropriate billing patterns or utilization trends of professional and institutional providers to the appropriate business owner.
• Communicates effectively with team members, other departments within the organization, management, members &/or providers.
• Assesses and educates members &/or providers on a proactive basis; utilizes internal, community and other healthcare resources as well as clinical knowledge to maximize outcomes.
• Contributes to reaching or exceeding departmental, divisional and corporate goals.
• Knowledgeable of business goals, progress toward accomplishment of goals and works collaboratively with peers to meet or exceed annual departmental targets.
• Analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction.
Qualifications
• Associate degree in nursing.
• 3+ years full-time direct patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics.
• Proven experience effectively presenting information and responding to questions from groups of managers, clients, customers, and the general public.
• Proven experience in problem definition, data collection to establish facts, and drawing valid conclusions to solve practical problems.
• RN license in Missouri and Kansas.
Preferred Qualifications
• Bachelor’s degree in nursing preferred.
• 1+ year(s) of utilization review, disease management, and/or case management experience.
• Knowledge of ICD, CPT and HCPCS coding.
• Knowledge of URAC and NCQA guidelines and state and federal regulations.
• Intermediate keyboarding skills.
• Intermediate knowledge of FACETS.
• Intermediate knowledge of Clinical Guidelines.
Benefits
• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute.
• Annual incentive bonus plan based on company achievement of goals.
• Time away from work including paid holidays, paid time off and volunteer time off.
• Professional development courses, mentorship opportunities, and tuition reimbursement program.
• Paid parental leave and adoption leave with adoption financial assistance.
• Employee discount program.