Job Abstract

Your Role

The Utilization Management team facilitates the review of requests for medical necessity to assure that care is provided to our members timely, at the correct level of care with quality and cost effectiveness standards. The Utilization Management Nurse Consultant will report to the Utilization Management Manager. In this role you will be an individual with advanced level knowledge. Considered the subject matter expert (SME) and could engage in project or program management activities.

Your Work

In this role, you will:

• Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare, MediCal and FEP
• Review for medical necessity, coding accuracy, medical policy compliance, benefit eligibility and contract compliance
• Identifies potential Third Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning .
• Provides referrals to Case management, Palliative Care, Disease Management, Appeals & Grievances and quality Departments as needed.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
• Triages and prioritizes cases and other assigned duties to meet required turn around times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Performs staff compliance audits and provides education to promote quality improvement
• Facilitate/scribe team meetings to engage staff, support processes and collaboration of team members.
• Provides SME and support to overall team.