Job DescriptionGathers 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. Mentors new Utilization Management (UM) staff and assists with training.
- Provides point of need support and coaching to UM professionals and other clinical team members in the course of normal operations. Builds UM team members' expertise through direct feedback and real-time coaching. Provides clinical, procedural or interpretation assistance. Completes audits and oversight for NCQA compliance; reviews phone compliance and productivity.
- Mentors and trains UM staff. Serves as a "buddy" to new UM Professionals during their first few months on the job by providing daily support and feedback, reviewing cases being recommended for approval by other UM nursing staff and aids in presentation to Medical Director.
- Researches and resolves escalated issues that front line UM professionals cannot resolve in a timely fashion. As necessary, takes escalated calls or fills-in for the UM team during high-peak periods.
- Works with the workforce planning team to perform data collection and analysis of trends to determine problem areas and strategies for better practices for the UM team.
- Develops and implements transition plans, as indicated, to ensure continuity of care.
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Refers cases to Physician team when the requested services do not meet medical necessity criteria. Works with customers on requests that are outside the contracted network.(Letters of Agreement process)
- Collaborates with the Care Management 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 meeting NCQA standards.
- Provides information to assist utilization management specialists regarding authorization, customer questions, appeal cases, etc.
- Interacts with Medical Directors and Physician Clinical reviewers 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 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.
- Interacts with providers and other team members in a professional, respectful manner.
General Job Information
TitleUtilization Management Professional Lead
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date12/15/2019
Date Requisition Created12/15/2019
Work ExperienceClinical, Utilization Management
EducationAssociates: Nursing (Required), Bachelors: Nursing, Bachelors: Social Work (Required), Masters: Social Work
License and Certifications - RequiredLCSW - Licensed Clinical Social Worker - 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, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - PreferredCCM - Certified Case Manager - Care Mgmt
Other Job Requirements
- Associates - Nursing
- Bachelors - Social Work
- Post degree in a clinical, medical setting.
- 5 years of experience conducting utilization management according to medical necessity criteria.
- RN or clinical credentials in the medical health plan field; may posses a Nurse Practitioner's license.
- Ability to use computer systems.
- Good organization, time management and verbal and written communication skills.
- Knowledge of medical 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 ICD and DSM IV coding or most current edition.
- Ability to analyze specific utilization problems and creatively plan and implement solutions.
- LCSW - Licensed Clinical Social Worker -
- LMHP - Licensed Mental Health Professional
- LPC - Licensed Professional Counselor
- LMFT - Licensed Marital and Family Therapist
- Master's Degree in Social Work.
- Bachelor's Degree in Nursing
- Current state Medicaid experience.
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.”