Utilization Management Professional

• Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
• Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information.
• Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.

lpn or rn
associate degree

• Caseload: 15-20 reviews per day which could be telephonic or via fax. The member population is mostly geriatric who reside in sub-acute nursing facilities.
• To be successful, the selected candidate must be comfortable working in a fast pace environment, documenting electronically, making ethically sound judgement, have strong organization, time management and communication skills and be a team player.
• Training: Is 4 – 6 weeks long weeks
• Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.- Maintains an active work load in accordance with performance standards.
• Works with community agencies as appropriate.- Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.