RN Utilization Management Coordinator - Prior Authorization - Health Alliance
Posted on: September 10, 2021
The Utilization Management Coordinator RN is responsible for
implementing medical utilization management functions for insured
and self-insured groups, including Medicare Advantage in all
service areas. Medical Utilization management functions include pre
authorization, inpatient care management, outcome data, file
audits, medical criteria review, and behavioral health management.
Staff will be assigned to specific functions based on staff skill
and department needs. Adheres to all mandated guidelines, including
NCQA, Department of Insurance, Department of Labor, and state and
- Acts as a resource to other departments regarding utilization
management matters, coverage guidelines, and assisting as needed
with clinical issues.
- Performs preauthorization process, inpatient review, and
retrospective review of requested services or pended claims based
on clinical documentation submitted, established medical necessity
criteria, organizational guidelines, and plan benefits within
established timeframes and in accordance with department
- 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, utilizing current Health Alliance criteria
(When Applicable to team needs).
- Refers members in care coordination when on-going needs are
- Works closely with member, family, providers and others to
coordinate care and best support member's needs.
- Explores opportunities for members to receive quality,
cost-effective care utilizing alternative settings or community
- Ensures all denial documentation is complete and includes all
review materials and criteria needed to make the decision.
- Forwards all appeals to Member and Provider Solutions
Department staff and assists, as needed, in compiling data and
documenting the sequence of events thoroughly.
- Provides clear, concise, accurate and timely documentation on
forms and in electronic systems as appropriate per departmental
- Provides written responses to members and physicians as needed
in a professional, accurate and timely manner.
Keywords: CARLE, Normal , RN Utilization Management Coordinator - Prior Authorization - Health Alliance, Other , Normal, Illinois
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