Utilization Management Specialist

California  ‐ Onsite
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Keywords

Description

Facilitation, coordination and approval of medically necessary referrals for direct lines of business (MCLA, Healthy Families, Healthy Kids) that meet established criteria.
  • Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.
  • Generates approval, modifications and denials communications, to include member and provider notification of referral determination.
  • Actively manages cases for applicable cases admitted in the acute or sub-acute settings.
  • Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review.
  • Monitors and oversees the collection and transfer of data (medical records) and referral requests.
  • Acts as a department resource for medical services request/referral management and processes.
SKILLS:

EDUCATION:
  • Required: Registered Nurses (RN) graduate; Associate Degree in Nursing
  • Preferred: Bachelor of Nursing or health care related field
LICENSES/CERTIFICATIONS
  • Required: RN License, Current, unrestricted California License
EXPERIENCE
  • Required: Clinical Nursing - 3 - 5 years, UM experience particularly in review of inpatient or sub-acute admissions; Utilization Management experience at HMO, hospital or PPG level
  • Preferred: Managed Care Medical experience, HMO - 3 years
Start date
n.a
From
Synectics
Published at
15.01.2015
Project ID:
835179
Contract type
Freelance
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