Description:
GENERAL SUMMARY
Responsible for implementing and coordinating all utilization management functions relating to preauthorization of outpatient testing/surgery, and inpatient admissions.
ESSENTIAL RESPONSIBILITIES
- Assists with the orientation of providers to the Plan's authorization and review procedures and work closely with participating physicians to secure information necessary for utilization management.
- Implements and documents utilization management activities, which incorporate a thorough understanding of clinical knowledge and appropriateness of medical services related to effective cost containment.
- Ensures the medical necessity and appropriateness of the delivery of healthcare resources provided to members as per their benefit package, through medical review of inpatient and outpatient service requests, utilizing established criteria, clinical judgment, and Medical Director guidelines.
- Actively participates in the negotiation and notification processes that result from the medical record reviews with the facilities. Prepares notification letters of denied and negotiated days within the established time frames.
- Offers safe, effective alternatives to the inpatient setting for those patients requiring interventions prior to their hospitalization. Actively negotiates transitional levels of care when services requested do not meet acute care criteria.
- Utilizes established criteria to authorize hospital admissions, diagnostic testing and ambulatory services, etc.
- Ensures that members are utilizing contracted providers requested services are covered benefits, medically necessary, appropriate and of the highest quality.
- Provides oversight of non-clinical staff in the screening of both verbal and written service requests. Serves as resource on clinical issues for non-clinical staff to ensure information provided to members and providers is current and accurate.
- Provides accurate, comprehensive, and pertinent utilization data and information.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for ensuring these issues are reported to the Quality Management Department.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state RN license preferred (MO & KS).
- Previous experience (usually 2+ years) in utilization management.
- Significant experience (usually 3+ years) clinical experience.
OR
- Licensed Practical Nurse with active state LPN license (MO & KS).
- Minimum 3 years utilization management experience required, and
- Minimum 5 years clinical experience required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Overland Prk, KS, US
Other Locations: ,
Organization: 13000 - CHC of Kansas
Schedule: Full-time
Job Posting: 2013-04-29 00:00:00.0
Job ID: 1311431
GENERAL SUMMARY
Responsible for implementing and coordinating all utilization management functions relating to preauthorization of outpatient testing/surgery, and inpatient admissions.
ESSENTIAL RESPONSIBILITIES
- Assists with the orientation of providers to the Plan's authorization and review procedures and work closely with participating physicians to secure information necessary for utilization management.
- Implements and documents utilization management activities, which incorporate a thorough understanding of clinical knowledge and appropriateness of medical services related to effective cost containment.
- Ensures the medical necessity and appropriateness of the delivery of healthcare resources provided to members as per their benefit package, through medical review of inpatient and outpatient service requests, utilizing established criteria, clinical judgment, and Medical Director guidelines.
- Actively participates in the negotiation and notification processes that result from the medical record reviews with the facilities. Prepares notification letters of denied and negotiated days within the established time frames.
- Offers safe, effective alternatives to the inpatient setting for those patients requiring interventions prior to their hospitalization. Actively negotiates transitional levels of care when services requested do not meet acute care criteria.
- Utilizes established criteria to authorize hospital admissions, diagnostic testing and ambulatory services, etc.
- Ensures that members are utilizing contracted providers requested services are covered benefits, medically necessary, appropriate and of the highest quality.
- Provides oversight of non-clinical staff in the screening of both verbal and written service requests. Serves as resource on clinical issues for non-clinical staff to ensure information provided to members and providers is current and accurate.
- Provides accurate, comprehensive, and pertinent utilization data and information.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for ensuring these issues are reported to the Quality Management Department.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state RN license preferred (MO & KS).
- Previous experience (usually 2+ years) in utilization management.
- Significant experience (usually 3+ years) clinical experience.
OR
- Licensed Practical Nurse with active state LPN license (MO & KS).
- Minimum 3 years utilization management experience required, and
- Minimum 5 years clinical experience required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Overland Prk, KS, US
Other Locations: ,
Organization: 13000 - CHC of Kansas
Schedule: Full-time
Job Posting: 2013-04-29 00:00:00.0
Job ID: 1311431