Utilization Management Coordinator – Lhb
| Company | HCSC |
|---|---|
| Location | New Mexico, USA, Kansas, USA, Pennsylvania, USA, Iowa, USA, Texas, USA, Montana, USA, Wisconsin, USA, North Carolina, USA, Oklahoma, USA, Missouri, USA, Illinois, USA, United States |
| Salary | $56700 – $106400 |
| Type | Full-Time |
| Degrees | Associate’s |
| Experience Level | Junior, Mid Level |
Requirements
- Unrestrictive Registered Nurse issued by a state or territory of the United States of America.
- Nurse with a minimum of two years clinical nursing and/or managed care experience.
Responsibilities
- Performs prospective, concurrent, and retrospective reviews to ensure the medical necessity and appropriateness of all hospital admissions and continues stays utilizing nationally recognized medical management criteria.
- Performs discharge-planning coordination unless this function is performed by a RN Care Manager, Case Management.
- Identifies alternative care interventions based on quality of care and cost effectiveness and communicates these options to the attending physician.
- Performs certification of outpatient surgeries and treatment.
- Performs prospective, concurrent and retrospective review of ancillary services.
- Conducts mandatory and discretionary second surgical opinion process.
- Refers all cases that do not meet applicable criteria or need a plan of care review to a Physician Advisor.
- Assists with the orientation of new Healthcare Management personnel and contributes to the ongoing networking of expertise with co-workers.
- Acts as a resource for peers and all other associates and clients.
- Performs medical claims review as required.
- Makes recommendations for system development from a user’s perspective.
- Assists in the preparation of reports that analyze and track quality of service and utilization statistics.
- Assists in special projects.
- Maintains a focus on timely customer service.
- Complies with Healthcare Management policies and procedures and conforms to the current URAC Utilization Management Standards while performing the job function.
- Reviews and completes the Corporate Confidentiality Attestation at the time of employment and routinely with periodic monitoring.
- Reviews and completes the Corporate Conflict of Interest Attestation at the time of employment and routinely with periodic monitoring.
- Maintains active state nursing license and continuing education requirements.
- Other duties as assigned by a Healthcare Management Supervisor or Director of Healthcare Management.
- Conforms to the requirements of the Corporate Code of Conduct.
- Complies with Healthcare Management Policies & Procedures while performing the job function.
- Promptly review, complete and acknowledge educational activities, which may include webinars, educational articles, etc. on an ongoing basis to comply with HCM continuing education requirements.
- Prioritize daily work assignment to meet division goals and customer requirements.
- Participates in Quality Improvement initiatives.
- Collaborate as necessary with internal and external customers to achieve excellent service results.
- Represents the Healthcare Management Division internally and externally with professionalism and demonstrated effectiveness.
- Acts as a resource to colleagues and all other associates and clients.
- Other duties and special projects as needed/assigned by HCM Management.
Preferred Qualifications
- Prior Utilization Management or Case Management experience preferred