RN Utilization Management Coordinator - Prior Authorization - Health Alliance

Company: CARLE
Location: Normal
Posted on: September 10, 2021

Job Description:

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 federal regulations.

• 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 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, utilizing current Health Alliance criteria (When Applicable to team needs).
• Refers members in care coordination when on-going needs are evident.
• 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 agencies.
• 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 standards.
• 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