Utilization Management Specialist

Utilization Management Specialist

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements to contribute to the determination of appropriateness and authorization of clinical services both medical and behavioral health.

Key responsibilities include determining medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references. Follow NCQA Standards, client Medical Policy, and departmental SOPS to manage member assignments.

Additionally, the role involves conducting research and analysis of pertinent diseases, treatments, and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborate with medical directors, sales and marketing, contracting, provider, and member services to determine appropriate benefit application. Apply sound clinical knowledge and judgment throughout the review process.

Make appropriate referrals and contacts as needed. Offer assistance to members and providers for alternative settings for care. Research and present educational topics related to cases, disease entities, and treatment modalities to interdepartmental audiences.

Required qualifications include a Bachelor's Degree in Nursing or an additional 4 years of relevant work experience in lieu of a degree. Five years of clinical nursing experience and 2 years of care management experience are also required. RN/LPN state licensing or compact is necessary. Working knowledge of managed care and health delivery systems is essential. Effective written and interpersonal communication skills, strong assessment skills, and proficiency in web-based technology and Microsoft Office applications are required. Ability to work effectively with large amounts of confidential member data and PHI, prioritize workload, multitask, and maintain a dynamic personal organization system is also necessary.

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.