Location: Webster,NY, USA
Summary:Utilization Management Reviewer (UR) is the critical evaluation of health care services provided to members using an integrated approach to determine the necessity and appropriateness of those services, with the purpose of controlling costs and monitoring quality of care. The Utilization Management Reviewer will play a key role in conducting these reviews and communicating the results of these reviews to all involved parties. The UM reviewer will facilitate the timely access to necessary, appropriate, high-quality services for members.Essential Job Functions:Conduct retrospective (post-service), concurrent, and prospective (pre-service) reviews of health care services to determine if these services meet plan covered status guidelines, and to determine the appropriateness and medical necessity of those servicesCompile and review the necessary documents and clinical records to effectively and accurately conduct the reviewsCollaborate with members of the interdisciplinary team to obtain current and accurate information, and where necessary, seek and acquire additional information as needed to assist with safe and appropriate health care decisionsCollaborate with other members of the interdisciplinary team to reach consensus on determinationsWill work cooperatively with providers of services to ensure members receive the right care, in the right place, at the right timeFully comply with all state and federal laws and internal policies to maintain the confidentiality of Protected Health Information (PHI) and financial informationIdentify suspected Quality of Care, risk, and utilization issues discovered during the reviews to the Quality Management Oversight Committee (QMOC)Comply with established time frames for conducting both urgent and non-urgent reviewsMeet performance benchmarks for the timeliness of reviews and communicating decisionsAdopt a thorough working knowledge of Medicaid and MLTC Rules and Regulations, clinical care guidelines, plan covered services, internal policies, and evidence-based nationally recognized medical necessity criteria such as InterQual® and MCG(Millman)®Conduct all reviews in harmony with these rules and regulations, guidelines, policies, and criteriaCommunicate the results of reviews, including denials for services, to all involved parties within established policy time frames, along with reasons for authorization or denial, supported by objective and unbiased criteria (see above)Comply with all UM Program guidelinesHelp develop workflows based on recognized best practiceProvides information to the QMOC and Chief Medical Officer to assist in revising UR Standard Operating Procedures when needed to adapt to changes in laws or criteria, or in response to workflow process improvement activitiesTracks statistics and trends, and reports to the QMOC/UM CommitteePerform all other duties relevant to the position as assigned by supervisor.Acts as Subject Matter Expert in Utilization Review and medical necessity criteriaContinually maintain clear, effective communication with teamCollaborate with other iCircle departmentsAdhere to ethical, legal, accreditation, certification, and regulatory standards and guidelines.Demonstrate cultural competence by being respectful of and responsive to the health beliefs, practices, cultural and language needs of the member and his/her support systemPerform all other duties relevant to the position as assigned by supervisor.Knowledge, Skills, and Abilities:Ability to work collaboratively and effectively with the interdisciplinary team members, iCircle members, families and providers.Ability to work independently and motivate othersAbility to communicate effectively, both orally and in writingExcellent verbal and written communication skills, expressing self in a clear, concise and professional manner.Possess strong computer skills and efficiency using Microsoft Word and other applicationsAbility to efficiently and competently navigate electronic medical recordsKnowledge of Medicaid and Medicare regulationsEducation and Experience:Bachelor's degree in NursingState licensure as a Registered Nurse (RN)Minimum 2 years of prior experience in Utilization ManagementThe listed salary range represents the organization's good faith and reasonable estimate of the range of possible compensation at the time of posting. The offered salary will be determined by: Applicant qualifications and experience, education, position specific licensing/training and departmental budgets.CDS Life Transitions is an Equal Opportunity Employer, and as such affirms the right of every person to participate in all aspects of employment without regard to gender, race, color, religion, national origin, ancestry, age, marital status, sexual orientation, pregnancy, disability, citizenship, military or veteran status, gender expression and/or identity, or any other status or characteristic protected by federal, state, or local law. CDS Life Transitions will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business. If you are interested in applying for an employment opportunity and feel you need a reasonable accommodation pursuant to the ADA, please contact us at 585-###-####.