Utilization Management Professional

Brooklyn NY 11201 Brooklyn 3 15 MetroTech Center SWH

Job Description

JOB SUMMARY

Under the direction of the Director of Clinical Operations and in coordination with the Medical Directors, the UR Nurse is responsible to conduct medical necessity reviews using evidence based clinical guidelines to review and evaluate all clinical services provided to our members. The UR Nurse will support our providers in delivering quality, evidence based care in an effort to reduce costly complications, optimize therapeutic outcomes, and improve the quality of life of our members.

Essential Functions



Review and evaluate all requests for elective inpatient admissions.

Review and evaluate all requests for services requiring pre-authorization.

Authorize inpatient and pre-authorization requests based upon evidence based

UM criteria, coverage guidelines and benefit structure.

Manage the daily inpatient census.

Conduct initial inpatient review and determine appropriateness of admission, anticipated length of stay and potential discharge needs.

Prioritize concurrent review of members.

Accept telephone and faxed clinical information and capture information in the member record in accordance with acceptable standards for documentation.

Assess and coordinate transitions of care settings including facility to facility and facility to home.

Generate organization determination notices in compliance with all regulatory standards for specific product line.

Expeditiously refer cases not meeting clinical guidelines/criteria to CMO for review.

Expeditiously alert providers of adverse determinations rendered by the CMO.

Appropriately refer cases to re-insurance carrier.

Actively participate in discharge planning processes, engaging assigned Care Manager for MLTC and DSNP members, member/family/caregiver, providers and vendors to ensure timely discharge, appropriate follow-up and continuity of care.

Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation for MAPD members.

Communicate with IDT as needed.

Refer cases with quality of care concerns to the CMO and Quality Assurance and Performance Improvement Department.

Alert Provider Relations tem regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained and entered into the member file.

Appropriately document all reviews, authorizations and adverse determinations in the Member file in Care Compass including diagnosis, procedures, providers, treatment plan, and Milliman criteria used to determine medical necessity. Paste Milliman criteria into progress note in member file.

Comply with all AlphaCare Care policies and procedures.

Participate in IDT meetings as appropriate.

Maintain privacy and security of all member and provider information in accordance with HIPAA.

Accept and perform additional duties as assigned within the scope of nursing practice, knowledge and skills.

Provide coverage for Care Managers as required.

MINIMUM REQUIREMENTS

NYS RN Lic or LPN
3+ years of experience

General Job Information

Title

Utilization Management Professional

Grade

24

Job Family

Clinical Services Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

1/28/2020

Date Requisition Created

1/28/2020

Work Experience

Clinical, Utilization Management

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

  • 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.
  • Associates - Nursing
  • Bachelors - Nursing
  • Bachelors - Social Work
  • Social Work Masters - Social Work
  • LISAC - Licensed Independent Substance Abuse Counselor certification
  • LCSW - Licensed Clinical Social Worker
  • LMHP - Licensed Mental Health Professional
  • LPC - Licensed Professional Counselor
  • LMFT - Licensed Marital and Family Therapist
  • 3 years of experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
  • Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
  • RN or clinical credentials in a behavioral health field.
  • If not an RN, must hold Masters or Doctoral Degree.
  • If LPN, must work under the direct clinical supervision of a Registered Nurse (RN) Case Manager, Registered Nurse Utilization Management Professional (UMP), or Registered Nurse Clinical Manager.
  • 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 ICD and DSM IV coding 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.”

Haita Makanji VP of Clinical Strategy and Programs at Magellan MRx