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RN Utilization Management Coordinator Medicare - FirstCarolinaCare

Company: CARLE
Location: Pinehurst
Posted on: October 9, 2021

Job Description:

The Utilization Management Coordinator is a Registered Nurse responsible for ensuring requests for specific health care services are medically necessary. Qualified candidates must demonstrate an aptitude for data management and information systems and a well-rounded clinical knowledge base. Must be able to work independently on a regular basis, as well as part of the Utilization Management team. Ability to change and adapt daily to the managed care environment and products. Excellent communication, organization and time management skills required. Ability to assess situations and make appropriate decisions based on benefit plans, Medical Policy and Procedures, and the most cost-effective care at the most appropriate setting. The Utilization Management Coordinator refers those requests which do not meet criteria to the Medical Director. The Utilization Management Coordinator also identifies situations whereby a referral to Case Management, Disease Management or care coordination is appropriate. Assist in the research and resolution of Appeals and Grievances.

  • Acts as a resource to other departments regarding utilization management matters, coverage guidelines, and assisting as needed with clinical or claims issues.
  • Performs authorization process, including but not limited to inpatient review, and retrospective review of requested services or pended claims based on clinical documentation submitted, established medical necessity criteria, organizational and regulatory guidelines, and plan benefits within established time frames and in accordance with department policy.
  • Assists with Inpatient Care Coordination oversight and performs inpatient reviews to coordinate care with providers, facilities, families and to ensure medical necessity, timely discharge and indicated referrals.
  • Enters approvals or denials into the Utilization Management documentation system, ensures all denial documentation is complete and includes all review materials and criteria needed to make the decision.
  • Limits medical necessity reviews to those services which are clearly included in the Member’s health benefit plan as covered benefits. For services for which clear criteria does not exist or benefits coverage is questionable, the coordinator refers the request to a supervisor, manager, director or Medical Director for further instructions, possible research and referral, and oversight of review.
  • Responds to Physician’s, health care provider’s and Member’s questions about the Utilization Management process, and as requested, provide copies of the criteria used for medical review determinations for the specific requested procedure or health care services.
  • Enters all pertinent demographic, clinical and applicable criteria references into the documentation system on a timely basis, including the reviewer’s signature, initials or unique electronic identifier at the time of each review. This includes entries related to referrals for a higher-level evaluation and any received instructions.
  • Adheres to the required timelines indicated for the types of reviews, types of decisions and appropriate notifications on each individual review and/or authorization request, as outlined in the organization’s policy which is in compliance with North Carolina state laws, federal regulations, Centers for Medicare & Medicaid Services regulations and the accrediting organization’s guidelines.
  • Ensures that all denials for authorization or certification of clinical services are determined by a North-Carolina licensed physician who is Board-Certified and has expertise related to the clinical request, and that all clinical documentation entered into the documentation system related to the review and subsequent denial is thorough and accurate.
  • Provides written responses to members and providers as needed in a professional, accurate and timely manner and ensures clear, concise accurate and timely documentation on forms and in electronic systems as appropriate per department standards.
  • Ensures the written denial notifications includes a description of appeal rights, the appeal process and the right of the Member in that process, and that the timelines for appeals are consistent with the urgency of the request related to the urgency of the review request.
  • Identifies Member’s who may benefit from the organization’s Care Management programs and makes those referrals, as indicated.
  • Assist in the review, resolution and response of Appeals & Grievances and ensures adherence with the appropriate regulatory guidance such as Department of Insurance CMS, or internal Policy & Procedures.
  • Works in tandem with the Appeals & Grievance Coordinator to ensure the appeal or grievance is processed timely and the response to the provider or member provides a detailed explanation of the plan decision and rationale and is written with descrip

Keywords: CARLE, Fayetteville , RN Utilization Management Coordinator Medicare - FirstCarolinaCare, Other , Pinehurst, North Carolina

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