Preferred Experience:

Minimum 3-5 years clinical practice with managed care, hospital nursing or utilization management experience.

Preferred License:

Utilization Management Certification (CPHM).

Summary:

Work with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Knowledge/Skills/Abilities

Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

Identifies appropriate benefits and eligibility for requested treatments and/or procedures.

Conducts prior authorization reviews to determine financial responsibility for client and its members.

Processes requests within required timelines.

Refers appropriate prior authorization requests to Medical Directors.

Requests additional information from members or providers in consistent and efficient manner.

Makes appropriate referrals to other clinical programs.

Collaborates with multidisciplinary teams to promote the client Care Model

Adheres to UM policies and procedures.

Occasional travel to other client offices or hospitals as requested, may be required. This can vary based on the individual State Plan.