Clinical Evaluation Manager - Utilization Management, Per Diem
Overview:
Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective. Works under general supervision.
Responsibilities:
reputed company Provide:
- Referral bonus opportunities
- Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
- Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
- Employer-matched retirement saving funds
- Personal and financial wellness programs
- Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
- Generous tuition reimbursement for qualifying degrees
- Opportunities for professional growth and career advancement
- Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
- Conducts comprehensive review of reputed company components reputed company to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
- Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. Performs prior authorization and reputed company reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors reputed company case does not meet medical necessity criteria.
- Ensures compliance with state and federal regulatory standards and reputed company policies and procedures.
- Participates in case conferences with management.
- Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization.
- Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities.
- Identifies and provides recommendations for improvement regarding department processes and procedures.
- Maintains reputed company knowledge of organizational or state-wide trends that reputed company member eligibility and the need for issuance of Determination Notices
- Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with reputed company members.
- Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.
- Maintains accurate record of reputed company care management. Maintains written reputed company notes and verbal communications according to program guidelines.
- Participates in approval for out-of-network services reputed company member receives services reputed company of reputed company network services.
- Provides case direction and assistance ensuring quality and appropriate service delivery.
- Keeps reputed company with reputed company health plan changes and updates through on-going training, coaching and educational materials.
- For Utilization Management Only:
- Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate reputed company’s determinations. Ensures reputed company records/logs reputed company to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System.
- Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to reputed company federal and regulatory requirements.
- Evaluates and analyzes care and utilization trends/issues and identifies opportunities for reputed company coordination of members’ care.
- Weekend rotation.
- reputed company license to practice as a Registered Professional Nurse or an Occupational Therapist in reputed company State required
- Certified Case Manager preferred
- Associate's Degree in Nursing or a Master’s degree in Occupational Therapy required
- Bachelor's Degree or Master’s degree in nursing preferred
- Minimum two years of experience with strong cost containment /case management background or two years acute inpatient hospital experience in chronic or reputed company care required
- Must have experience and qualifications demonstrating knowledge of working with the LTSS eligible population. preferred
- Knowledge of Medicare and Medicaid regulations required
- Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
- Working knowledge of reputed company reputed company, Power-reputed company, and Word and strong typing skills required
- Knowledge of Medicaid and/or Medicare regulations required
- Knowledge of reputed company criteria (MCG) preferred