Utilization Management Professional - Per Diem

Bridgewater MA 02324 One Lakeshore Center

Job Description

Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
  • Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
  • In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
  • Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
  • Maintains an active work load in accordance with performance standards.
  • Works with community agencies as appropriate.
  • Participates in network development including identification and recruitment of quality providers as needed.
  • Advocates for the enrollee to ensure health care needs are met.  Interacts with providers in a professional, respectful manner. 
  • Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

General Job Information

Title

Utilization Management Professional - Per Diem

Grade

24

Job Family

Clinical Services Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

9/24/2019

Date Requisition Created

9/24/2019

Work Experience

Medical

Education

Associates: Nursing (Required), Bachelors: Nursing, Masters: Social Work (Required)

License and Certifications - Required

LCSW - Licensed Clinical Social Worker - Care Mgmt, LISAC - Licensed Independent Substance Abuse Counselor - Care Mgmt, LMFT - Licensed Marital and Family Therapist - Care Mgmt, LMHP - Licensed Mental Health Professional - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, LPN - Licensed Practical Nurse - Care Mgmt, LSW - Licensed Social Worker - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements

Responsibilities

Home Care, Long-Term Care, MLTC experience preferred, including appropriate support services in the community and accessing and using durable medical equipment (DME). Experience in utilization review, concurrent review and/or risk management a plus. Bi or multilingual ability preferred.Minimum 3 years clinical experience with focus in managed care, including disease or case management.Understands and is able to apply principals of Care Management and Person Centered Service Planning. Ability to apply Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines. Ability to understand and apply coverage guidelines and benefit limitations. Familiar with clinical needs and disease processes for chronic physical and behavioral illnesses (depression, challenging behaviors, Alzheimer?s disease and other disease-related dementias). Understands and adapts appropriately to issues related to communication, cognitive or other barriers. Ability to lead an interdisciplinary care team. Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner. Comfortable with conducting home visits and commuting within the service area.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”