Job Description

Job Summary In addition to the responsibilities listed below, this position is also responsible for applying advanced clinical and regulatory knowledge of evidence‑based guidelines, insurance policies, and clinical criteria to consult on the medical necessity, level of care, and duration of treatment required for moderately complex reviews, and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating and/or adjudicating referrals to appropriate services based on medical necessity. Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self‑development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome. Completes work assignments autonomously by applying up‑to‑date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross‑functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team. Provides high‑quality consultation by: facilitating and communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care; and leveraging comprehensive knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians. Supports education and compliance initiatives by: remaining up‑to‑date and sharing information with the team on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and supporting the development and delivery of education and training programs for staff and physicians at the local level to promote best practices in utilization management. Assists in quality improvement efforts by: conducting standard data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement; providing input and participating in the implementation of corrective action plans to address deficiencies in utilization review workflows/processes; actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost‑effective care; and developing and refining desk‑level procedures (e.g., workflows). Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to internal team members, and recommending appropriate actions for moderately complex member cases. Knowledge, Skills and Abilities: Core Ambiguity/Uncertainty Management Attention to Detail Business Knowledge Communication Critical Thinking Cross‑Group Collaboration Decision Making Dependability Diversity, Equity, and Inclusion Support Drives Results Facilitation Skills Health Care Industry Influencing Others Integrity Learning Agility Organizational Savvy Problem Solving Short‑ and Long‑term Learning & Recall Teamwork Topic‑Specific Communication Knowledge, Skills and Abilities: Functional Medical Terminology Nursing Principles Acts with Compassion Confidentiality Consulting Coordination Evidence‑Based Medicine Principles Leverages Technology Quality Assurance and Effectiveness Relationship Building Written Communication Minimum Qualifications Bachelors Degree in Nursing AND minimum three (3) years of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a directly related field. Registered Nurse License (California) required at hire. Preferred Qualifications Two (2) years of experience in utilization review/management. #J-18808-Ljbffr

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