Utilization Management Reviewer, RN (SN LTSS & Duals)

Job Description: Summary: This position is responsible for coordinating, integrating, and monitoring the utilization of physical health (PH) medical and healthcare services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs. Participates in rotating on-call schedule, as required, to meet departmental time frames. Per department needs, may be responsible for additional hours. Essential Accountabilities: Level I Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members’ medical health conditions, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates. May perform clinical review telephonically, electronically, or on-site, depending on customer and departmental needs. Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical knowledge, members’ specific health plan benefits, and efficient care delivery processes. Ensures compliance with corporate and departmental policy and procedure, identifies and refers potential quality of care and utilization issues to Medical Director. Utilizes appropriate communication techniques with members and providers to obtain clinical information, assesses medical necessity of services, advocating for members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care. Collaborates with hospital, home care, care management, and other providers effectively to ensure that clinical needs are met and that there are no gaps in care. Acts as a resource and liaison to the provider community in conjunction with Provider Relations, explaining processes for accessing Health Plan to perform medical review, obtains case or disease management support, or otherwise interacts with Health Plan programs and services. Makes accurate and consistent interpretation of required clinical criteria, medical policy, contract benefits, and State and Federal Mandates. May be responsible for pricing, coding, researching claims to ensure accurate application of contract benefits and Corporate Medical Policies. Accountable for meeting departmental guidelines for timeliness, production and metrics and meeting requirements established for audits to ensure adherence to regulatory and departmental policy/procedures. Maintains compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements. Assists with training and special projects, as assigned. Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) Offers process improvement suggestions and participates in the solutions of more complex issues/activities. Mentors staff and assists with coaching, as necessary. Provides consistent positive results on audits. Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health. Manages more complex assignments; cross-trained to review various levels of care and/or services. Participate in committees and lead when required Level III (in addition to Level II Accountabilities) Displays leadership and serves as a positive role model to others in the department. Identifies, recommends and assesses new processes to improve productivity and gain efficiencies for performance improvement opportunities in the Utilization Management Department. Assists in updating departmental policies, procedures, and desk level procedures relative to the functions Expert and resource for escalations - Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems. Mentor (to others in department) - Provides guidance and leadership to the daily activities of the Utilization Management Department clinical staff. Acts as resource to Utilization Management staff, members and providers. Provides backup for the Supervisor, whenever necessary. Participates in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care. Assists Medical Director (MD) in projects as needed. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels Associates degree and active NYS RN license required. Bachelors degree preferred. Minimum of three years of clinical experience required. Utilization Management experience preferred. Must demonstrate proficiency with the Microsoft Office Suite Demonstrates general understanding of coding standards Maintains current and working knowledge of Utilization Management Standards. Experience in interpreting managed care benefit plans and strong knowledge of government program contracts (Medicare and Medicaid) and benefits, preferred. Strong written and verbal communication skills Ability to multitask and balance priorities. Must demonstrate ability to work independently on a daily basis. Deliver efficient, effective, and seamless care to members. Level II (in addition to Level I Qualifications) Minimum of 2 years in utilization management position. Demonstrates ability to elevate to management, as necessary. Demonstrates proficiency in all related technology Ability to take on broader responsibilities Ability to participate in training of new staff Level III (in addition to Level II Qualifications) Must have been in a utilization management position or similar subject matter expert for at least 5 years. Broad understanding of multiple areas (i.e. UM and CM). Incumbent is required to know multiple functional areas and supporting systems. Expert in Utilization Management and ability to handle complex assignments, challenging situations and highly visible issues. Ability to lead the training of new staff. Demonstrated presentation skills. Physical Requirements: Ability to travel across the health plan service regions as needed. Ability to work at a computer for prolonged periods of time. ************ In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation Range(s): Level I: Grade E2: Minimum: $62,400 - Maximum: $96,081 Level II: Grade E3: Minimum: $62,400 - Maximum: $106,929 Level III: Grade E4: Minimum: $65,346 - Maximum: $117,622 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case by case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. #J-18808-Ljbffr Excellus BCBS