:: Careers

Utilization Management Clinician - Medical

REPORTS TO: Director of Care Management
SUPERVISES: None

JOB SUMMARY: The Utilization Management Clinician is responsible for conducting utilization and quality management activities in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities. This is a full time position.

MINIMUM QUALIFICATIONS:

Education: Registered Nurse with a current, unrestricted license.

Experience: One to two years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred. One to two years directly related experience using InterQual criteria or healthcare criteria preferred. Two (2) years experience in a hospital-based nursing required. Medical-surgical care experience preferred for positions in medical management areas. Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred. LPNs must have three years previous Utilization Management experience. Call center knowledge desired.

Knowledge/skills:

Strong communication, documentation, clinical and critical thinking skills essential.
Working knowledge of utilization management/case management preferred.
Strong problem solving and decision making skills essential.
Strong typing and computer skills essential

ACCOUNTABILITIES:

Job Performance/Responsibilities:

Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities;
Must become knowledgeable of URAC requirements for clinical staff for UM accreditation;
Performs telephonic review for inpatient and outpatient services using InterQual criteria or Health Integrated behavioral health criteria;
Collects only pertinent clinical information and documents all UM review information using the appropriate software system;
Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with health plan clients;
Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
Recommends, coordinates and educates providers regarding alternative care options;
Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement;
Participates in UM program CQI activities;
Communicates all UM review outcomes in accordance with the health plan client profile procedures;
Follows relevant client time frame standards for conducting and communicating UM review determination;
Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures;
Identifies and communicates to the Director of Care Management all hospital, ancillary provider, physician provider and physician office concerns and issues;
Identifies and communicates to the Director of Utilization Management supervisor all potential quality of care concerns and patient safety;
Serves as liaison for provider staff and the health plan client;
Maintains courteous, professional attitude when working with Health Integrated HealthCare staff, hospital and physician providers, and health plan client;
Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high risk cases for case management referral;
Active participation in team meetings; and
Performs other duties as requested by the Director of Care Management.

Return to Careers Page