Job DescriptionUnder general supervision, and in collaboration with Medical Directors and other members of the clinical team, the Utilization Management (UM) Professional gathers and synthesizes clinical information in order to authorize services. The UM Professional 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. This position 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
TitlePhysical Health Utilization Management Professional
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date11/25/2019
Date Requisition Created11/1/2019
Work ExperienceClinical, Utilization Management
EducationAssociates: Nursing (Required), Bachelors: Nursing, Masters: Social Work (Required)
License and Certifications - RequiredLCSW - 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
- Bachelor in Nursing
- Able to demonstrate the ability to quickly develop an alliance with providers via telephone.
- On call coverage of Nurse Line as requested or required of position.
- Associate in Nursing
- 3+ years of experience post degree in a clinical, medical/surgical and/or physical health care setting.
- 3+ years of experience conducting utilization management according to medical necessity criteria.
- RN or LPN license
- Ability to use computer systems.
- Good organization, time management and verbal and written communication skills.
- Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
- Knowledge and experience in diverse patient care settings including inpatient care.
- Ability to function independently and as a team member.
- Knowledge of MCG and/or Interqual criteria or most current edition.
- Ability to analyze specific utilization problems and creatively plan and implement solutions.
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.”