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Company

Clearlink Partners · 21 hours ago

Utilization Management Coordinator

United States

Full-time

Remote

Entry, Mid Level

$50K/yr - $70K/yr

2+ years exp

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Responsibilities

Gather and organization documentation to support fully utilization review

Review cases utilizing industry standard clinical guidelines and organizational medical policy to ensure appropriateness of care

Leverage information from the utilization review process to refer Members to care management, as needed

Document findings against criteria to approve cases that are consistent with the approved criteria sets

Refer cases to RN/ physician reviewer(s) that do not clearly meet approved criteria sets for further review/ interpretation

Maintain documentation associated with all reviews to ensure decisions are timely and in compliance with all applicable regulations and contracted standards

Prepare and transmit decision response letters, as needed

Ensure that all necessary clinical information is available to allow for a complete and fair review

Outreach as necessary to providers/ staff for clarification or additional information required

Prepare documentation and case summary for further review to support appropriate decision-making

Ensure rationales are appropriate and supported by guidelines in accordance with requirements

Access and review various resources to support decisions (i.e. MCG, InterQual)

Design utilization management programs, processes and workflows to meet operational goals and anticipate future strategic needs

Evaluate ability to automate and streamline standard work

Analyze and monitor quality, cost reimbursement and utilization trends

Develop and oversee inpatient and outpatient utilization management programs to ensure

Cost-effective use of patient care resources

Case delivery at the most appropriate level

Collaboration with the medical staff on resource utilization issues

Compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates

Maintaining timely and effective internal and external communication regarding assigned work/ tasks

Logging, tracking, and ensuring completion of all work in compliance with contract service standards

Tracking review completion of assigned work to ensure final closure/ resolution

Managing high workload volumes, ensuring accuracy and compliance with contractual deadlines

Ensuring all necessary information is available and organized for professional staff review/resolution

Outreach as necessary for clarification or collection of additional information needed

Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines

Qualification

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Utilization ManagementMedicare AdvantageManaged MedicaidDual SNPCommercial Lines of BusinessLPN LicenseMedical Necessity DecisionsMicrosoft OfficeCritical AnalysisCare Standards Knowledge

Required

Excellent oral and written interpersonal/communication

Strong internal/external customer-service, organizational, multitasking, and teamwork skills

Excellent analytical thinking/problem-solving skills

Proficiency in Microsoft Office

Ability to perform critical analysis and facilitate/ promote positive outcomes

Ability to work effectively in a fast-paced environment with multiple priorities, deadlines, and workloads

Ability to offer positive customer service to every internal and external customer

2+ years of experience work for a Managed Care (Payer)

Demonstrated experience with utilization management practices in multiple lines of business (LOBs) including: Medicare Advantage, Managed Medicaid, Dual SNP, Commercial Lines of Business

Knowledge of current access and care standards including over and under utilization

Knowledge and competency with all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care

Must be able to sit in a chair for extended periods of time

Must be able to speak so that you are able to accurately express ideas by means of the spoken word

Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices

Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse

Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types

Must be able to fluently communicate both verbally and in writing using the English language

Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously