Lead Utilization Management Professional - Magellan Health - Miami, FL
Gathers and synthesizes medical info to be able to authorize providers. Critiques well being care providers to find out consistency with contract necessities, protection insurance policies and proof-based mostly medical necessity standards; collects and analyzes utilization info; assists with program processes for transitions throughout ranges of care together with discharge planning and ambulatory comply with up exercise. Serves as an skilled useful resource on protection insurance policies, coated advantages, and medical necessity standards. Mentors new UM employees and assists with coaching.ESSENTIAL FUNCTIONS: – Offers level of want help and training to Utilization Management professionals and different medical staff members in the middle of regular operations. Builds UM workforce members experience via direct suggestions and actual-time teaching. Is on the market to offer medical, procedural or interpretational help.- Mentors and trains UM employees. Serves as a “buddy” to new UM Professionals throughout their first few months on the job by offering day by day help and suggestions, reviewing instances being really helpful for approval by different UM nursing employees and aids in presentation to Medical Director. – Researches and resolves escalated points that frontline UMPs can’t resolve in a well timed trend. As needed, takes escalated calls or fills-in for the UM workforce throughout excessive-peak durations.- Works with the workforce planning workforce to carry out knowledge assortment and evaluation of tendencies to find out drawback areas and methods for higher practices for the UM staff.- Develops and implements transition plans, as indicated, to make sure continuity of care. Negotiates and paperwork single case agreements in accordance with the corporate’s procedures.- Critiques deliberate, in course of, or accomplished well being care providers to make sure medical necessity and effectiveness in accordance with proof-based mostly standards. Proposes options when the requested providers don’t meet medical necessity standards or are outdoors the contracted community. As assigned and based mostly on credentials, screens and critiques specialised requests and remedy data similar to Remedy Document Varieties.- Collaborates with the Care Coordination Group to implement help for transitions in care. Facilitates well timed sharing of enrollees’ medical info (akin to earlier remedy, drugs, and deliberate care) as a way to promote continuity of care.- Offers info to enrollees, suppliers, and inner employees relating to coated and non-coated advantages, group assets, company packages, and firm insurance policies and procedures and standards.- Interacts with Medical Administrators and Doctor Advisors to offer case info and talk about medical and authorization questions and considerations relating to particular instances. Assures that case documentation for every determination is full, together with associated correspondence.- Participates in Care Coordination Staff and utilization management actions, together with collaboration with different employees on enrollee instances, and performing knowledge assortment, monitoring, and evaluation.- Maintains an lively work load in accordance with efficiency requirements.- Advocates for the enrollee to make sure well being care wants are met; Interacts with suppliers in knowledgeable, respectful method.- Offers protection of Nurse Line and/or Disaster Line as requested or required for place.MINIMUM QUALIFICATIONS• Schooling: Associates Diploma in Nursing• Work Expertise: 5+ years Submit diploma in a medical, medical setting. Additionally requires minimal of 5 years of expertise conducting utilization management in line with medical necessity standards.• Licenses and Certifications: Care MgmtRN – Registered Nurse, State and/or Compact State Licensure Required; Care MgmtCCM – Licensed Case Supervisor Most popular Different Job Necessities• RN or medical credentials within the medical well being plan area. Can posses a Nurse Practitioner license.• Potential to make use of pc methods.• Good group, time management and verbal and written communication expertise.• Information of medical utilization management procedures, Medicaid advantages, group assets and suppliers.• Information and expertise in numerous affected person care settings together with inpatient care.• Capacity to perform independently and as a staff member.• Information of ICD and DSM IV coding or most present version.
Accordingly, AmeriCorps alumni, returned Peace Corps volunteers and different nationwide service individuals are inspired to use to our job openings.Common Job Info TitleLead Utilization Management ProfessionalJob FamilyCare ManagementCountryUnited States of AmericaFLSA StatusUnited States of America (Exempt)Recruiting Begin Date2/9/2016Date Requisition Created2/9/2016Minimal QualificationsEducationAssociatesAssociates: Nursing (Required)License and CertificationsCCM – Licensed Case Supervisor – Case Mgmt/Social Providers, RN – Registered Nurse, State and/or Compact State Licensure – Care MgmtOther Job RequirementsResponsibilitiesPost diploma in a medical, medical setting. Additionally requires minimal of 5 years of expertise conducting utilization management in line with medical necessity standards., Favor current Florida Medicaid expertise.Capable of show the power to shortly develop an alliance with suppliers by way of phone., RN or medical credentials within the medical well being plan subject. Can posses a Nurse Practioner license.Capacity to make use of pc methods.Good group, time management and verbal and written communication expertise.Information of medical utilization management procedures, Medicaid advantages, group assets and suppliers.Information and expertise in numerous affected person care settings together with inpatient care.Potential to perform independently and as a group member.Information of ICD and DSM IV coding or most present version. Capacity to research particular utilization issues and creatively plan and implement options.CompetenciesLanguage(s)Magellan Health Providers is proud to be an Equal Alternative Employer and a Tobacco-free office. EOE/M/F/Vet/Disabled |
Magellan Health Providers, Inc. (Magellan) is engaged within the specialty managed healthcare enterprise. Magellan supplies providers to well being…
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