Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits in the concurrent review/utilization management setting. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness.
Fundamental Components: Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members in the concurrent review setting Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers, medical directors and other parties to facilitate medically necessary care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations
3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Managed care/utilization review experience preferred Must be proficient with computers and be able to quickly navigate multiple internet applications
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS: Nursing/Registered Nurse is required
ADDITIONAL JOB INFORMATION Become part of an innovative and collaborative team that assists in ensuring that members have access to the care they need at the right time and in the right setting.