Previous Job
Previous
Senior Utilization Management Professional - RN
Ref No.: 18-13884
Location: Richmond, Virginia
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.

ESSENTIAL FUNCTIONS:
- 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 policies and 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