Purpose Statement /Position Summary

Under minimalsupervision and using clinical experience, evidence based knowledge and incollaboration with our physicians, to process clinically appropriate caremanagement referrals.

Essential Functions andResponsibilities of the Job

• Along with physician hospitalists / PCPs / Specialists, leads and coordinates activities of interdisciplinary treatment team required to make complex clinical, benefit and network decisions.
• Analyze data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with MemorialCare Medical Foundation strategic goals and objectives.
• Apply Utilization Review Management process to ensure continuity of care throughout the health care continuum including review and authorization of services applying evidence-based guidelines and per MemorialCare Medical Foundation policy.
• Assures review turnaround times adhere to timeliness standards set by contracting and regulatory requirements and established productivity and quality guidelines.
• Decisions and documentation demonstrates prudent utilization of resources, identifies for potential cost reduction; promote quality care and comply with regulatory guidelines needed to maintain delegated status from contracted health plans.
• Assists with developing corrective action plans, create policies and design workflows that operationalize improvements identified through data and leadership analysis.
• Documents decisions that demonstrate independent judgment, critical thinking and application of complex managed care regulations including but not limited to benefit structures, health plan coverage, medical necessity, network contract, financial responsibility and care management.
• Implement and maintain systems and processes that meet various regulatory requirements.
• Interprets and applies delegation agreements, divisions of financial responsibility, contracted provider lists, evidence of coverage, health plan operations manuals, and MemorialCare Foundation policy.
• Independently research and determine the information necessary to satisfy specific business and regulatory medical management requirements. Initiate and complete the denial process for all services deemed to be non-covered benefits or not medically necessary.
• May be called upon to participate in regulatory compliance audit requirements and activities/committees including but not limited to Utilization Management, Quality Improvement and Performance Improvement.
• Maintain and demonstrate a complete understanding of own scope of practice of licensure and education level.
• Monitors utilization and provides recommendations for improvement against established industry standards and performance measurement metrics.
• Works with Managers to oversee approval, denial and appeal process, including implementation of appropriate denial letter language to meet regulatory standards.
• Participates in Contracting and Provider Relations activities as necessary to develop and maintain provider networks.
• Subject to standard medical management performance measurements for specific area/team including but not limited to referral turnaround times, volume, denial language and overturn rates.
• May be required to travel during shift for meetings and staff oversite.
• May be required to work remote to meet business needs for regulatory compliance.

Essential Job Outcomes

• Collect case specific and health plan specific criteria when reviewing the medical necessity and benefit coverage of prospective, concurrent and retrospective review requests
•  Reviews each request to determine if the services are being requested for delivery in the most appropriate setting, within the criteria guidelines of the health plan, within the contractual requirements, and being  provided in the most cost efficient methods for care delivery with the goal of achieving the best outcome for the member
• Immediately communicates to the Medical Director; barriers, requests not meeting criteria or guidelines, questions of medical appropriateness or medical necessity, or any other issues or concerns.
• Adheres to all Medical Management Policies and Procedures and Follows all HIPAA standards and reporting requirements.
• Assists all members of the Medical Management Department and Assists Member Services Department in the communication of benefit coverage, limitations and review determinations.