Responsible for preauthorization and on-going review of all durable medical equipment, durable medical supplies and home modifications. Utilizes internal criteria and/or nationally recognized criteria sets and InterQual® for the clinical review of pediatric and young adult member authorization requests. Responsible for both the management of resources and the achievement of desired outcomes for members with ongoing communication to the Director of Utilization Management, the Chief Medical Director and staff for coordination of care and continued management of members.
Essential job duties:
- Ensures compliance with standard guidelines, policy and procedures and updates for utilization review.
- Demonstrates accuracy in the use of InterQual®, CMS or other approved internal guidelines.
- Demonstrates compliance with authorization timeliness based on assessment of past due cases.
- Demonstrates compliance in case closure.
- Demonstrates time and attendance.
- Demonstrates scores of at least 80% on inter-rater reliability testing for all InterQual® assigned modules.
- Demonstrates preparation and participation in daily huddles, inpatient rounds, weekly department meetings and assigned committee meetings.
- Demonstrates assessment of compliance with work flow and department processes.
- Performs reviews within designated timeframes (or first business day) after initial auth request to determine medical necessity and appropriateness of care.
- Demonstrates compliance with HSCSN’s Rules of Conduct.
- Organizes utilization management caseload based on daily volume, and complexity of individual processes.
- Maintains current knowledge of laws, regulations, and interpretation of utilization review, Medicaid/Medicare and commercial insurance.
- Actively contributes as a team member to utilization of resources within the department.
- Conducts retrospective reviews for medical necessity and continued stay.
- Conducts prospective reviews for medical necessity.
- Documents all review decisions of Home Modification approvals in IT system at time of review, and closes all cases once complete.
- Participates in Home Modification rounds with the Chief Medical Officer/Director Utilization Management and presents an accurate and concise criteria/internal guideline-based report.
- Ensures all Home Modification Request packets are complete.
- Generates timely authorizations for home evaluations. Monitors completion within 60 days.
- Participates as a member of the Benefit Utilization Management Committee, project teams and meetings as assigned.
- Proactively contacts the requesting provider if review does not meet criteria or additional information is required to complete the review.
- Collaborates with appropriate staff to identify and coordinate utilization and discharge issues.
- Develops a collaborative relationship with the medical staff and the healthcare team for obtaining and organizing resources for patient care which are consistent with payer regulations, contract agreements and/or benefits coverage.
- Refers case not meeting medical necessity for review and determination in accordance with department guidelines.
- Reports quality of care sentinel event activities to Quality and Risk Management when identified.
- Routes information regarding completed authorizations to providers and care givers.
- Completes initial and reauthorization of service requests within the specified time frames.
- Clearly communicates, verbally and in writing, to physician /ancillary service providers.
- Seeks advice from UM Director or other designated person(s) with expertise in specialty area when necessary.
- Protects and secures all identifiable personal health information according to HIPAA requirements. Maintains a high degree of confidentiality on all enrollee information.
- Communicates, as needed, with home health provider, care manager and others to coordinate care.
- Assesses patient insurance benefits. Coordinates with providers, as appropriate.
- Maintains current knowledge of laws, regulations, and interpretations of utilization
- Assists with orientations, cross training, and skill development of staff members as scheduled.
- Two years in utilization management in a managed care environment.
- Experience utilizing nationally recognized criteria sets (InterQual/MCG).
- Five years of sound medical/surgical, home health care, pediatric and/or behavioral health experience preferred.
- Proficiency in word processing and spreadsheets.
- Excellent interpersonal, organizational, and written and verbal communication skills required.
- Ability to complete multiple complex assignments.
- Appreciation and sensitivity of cultural diversity.
- Professional decorum.
- Strong analytical, critical thinking and problem solving skills.
Licensed as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Social Worker (SW) in the District of Columbia. Certification in utilization review preferred.
Bachelor’s degree preferred.
DC Residents are encouraged to apply!