Job Description
Essential Duties and Responsibilities include the following:
- Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.
- In collaboration with the Medical Director, identifies the need for and participates in the development and implementation of Utilization Management policies and procedures and to promote cost-effectiveness and improved quality.
- Oversee compliance with all health plan, state and federal regulatory requirements (e.g., DMHC, Medicaid, CMS Medicare Part C & D, NCQA where applicable) with respect to prior authorization services, such as turnaround times and appropriate documentation.
- Understand CMS and ICE UM processes/policies/procedures, especially with respect to ICE and CMS denial language and timeliness criteria, with respect to prior authorization services.
- Provide direct supervisory oversight to prior authorization review nurses, professional claims review nurses, coordinators and compliance staff, including, but not limited to daily work assignments, special project assignments, assistance with performance reviews and disciplinary actions as needed/required.
- Communicate effectively and functions as liaison between nurse and physician reviewers, medical directors, coordinators, PCP and specialist providers, and health plans daily or as indicated regarding any UM or referral authorization issues, as well as care coordination issues.
- Oversight of the professional claims review nurse team (nurses/coders), who work with the claims department to assist in making medical necessity determinations of submitted claims.
- Demonstrates the ability to follow through with requests, sharing of critical information, returning phone calls and getting back to individuals in a timely manner.
- Sets an example for staff by maintaining exemplary compliance and privacy, and reporting compliance and privacy issues and facilitating resolution of others’ issues.
- Assists as necessary in gathering/preparing necessary reports, such as department work-plans, quarterly/semi-annual/annual reports, inter-rater reliability surveys, and plan audits.
- Works with the Utilization Management Committee Chair, and when necessary Medical Management Vice Presidents, Chief Medical Officers or Medical Directors to coordinate activities and Utilization Management Committee meetings.
Job Requirements:
- Five years of progressive prior-authorization experience or related experience in a medical group, IPA or management company required, with prior authorization experience recommended.
- Prior experience with project development and implementation, and have excellent organizational, interpersonal and analytical skills.