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Utilization Management
Ref No.: 17-00329
Location: Rancho Cordova, California
Start Date: 02/07/2017
Utilization Management-Rancho Cordova, CA
Day to Day Responsibilities of this Position and Description of Project: Performs advanced or complicated case review and determines first level approvals for prior authorization of services, inpatient, outpatient and/or ancillary services.
The review process requires interpretation and application of evidenced based criteria as established by medical policy and other approved resources.
Clinical judgment and detailed knowledge of benefit plans used to complete review decisions.
Acts as liaison between the member, the provider, and the health plan to utilize appropriate and cost effective resources.
Goal is Discharge (DC) planning and to return patient to cognitive and physical condition prior to event that triggered treatment.
  • Performs prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP.
  • Ensures diagnosis matches ICD9 codes. Conduct UM/care management (CM) review activities with delegated entities as necessary. Manages member treatment to meet Recommended Length of Stay. Ensures discharge (DC) planning at levels of care appropriate for the member needs and acuity. Determines discharge (DC) plan by assessing cognitive and physical status. Determines post-acute needs of patient, levels of care, equipment, how event is going to impact patient’s status.
  • Ensures quality, cost-effective DC planning. Triages and prioritizes cases to meet required turn-around times. Expedites access to appropriate care for members with urgent needs using expedited review process. Prepares and presents cases to Medical Director (MD) as required by law for medical necessity determination. Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements. Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
  • Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.
  • Identifies potential Third Party Liability and Coordination of Benefit cases and notifies appropriate internal departments. Manages multiple complex cases including lower level of care.
If you or someone you know is interested, please email me your updated resume, and give me a call!
Ebony Fisher
Avalon Healthcare Staffing-Sr. Healthcare Recruiter