Summary of Position

• Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department.
   
• Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.

Principal Accountabilities

• Under the direction of the leader, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
   
• Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting. 
   
• Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
   
• Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards.
   
• Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
   
• Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
   
• Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
   
• Prepare and present clinical case summaries in routine inpatient rounds.
   
• Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
   
• Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
   
• Actively participate on assigned committees.
   
• Perform other related projects and duties as assigned.

Qualifications

Education, Training, Licenses, Certifications

• Associate’s degree or bachelor’s degree in nursing.
   
• Valid RN License without restriction. 
   
• May require a CME accreditation in specific specialties.
   
• Certification in utilization or care management preferred

Relevant Work Experience, Knowledge, Skills, and Abilities

• 4 – 6+ years of Nursing experience.
   
• Case and/or utilization management/care coordination and managed care experience. 
   
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience. 
   
• Organizing and prioritizing skills, and strong attention to detail.
   
• Trained in the use of Motivational Interviewing techniques. 
   
• Experience working in physician practice and/or with electronic medical records. 
   
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
   
• Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).