Job Description
Job Summary Conducts reviews of medical records and treatment plans to evaluate and consult on necessity, appropriateness, and efficiency of health care services and provides expert guidance to team members. Drives the communication efforts with physicians, managers, staff, members and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care. Identifies utilization trends, leads efforts for improvement initiatives, and facilitates the development and implementation of corrective action plans to address deficiencies, evaluate effectiveness, and track improvements in utilization review workflow/processes and ensure compliant and cost-effective care. Facilitates education and compliance initiatives by remaining up-to-date on the relevant regulations and guidelines and driving the development and delivery of education and training programs for staff and physicians to promote best practices in utilization management at the local and regional level.
Essential Responsibilities - Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.
- Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.
- Promotes high-quality consultation by: driving communication efforts with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care and proactively resolving communication issues within the work team; and leveraging expert 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.
- Facilitates education and compliance initiatives by: remaining up-to-date and sharing information with cross-functional teams on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and driving the development and delivery of education and training programs for staff and physicians at the local and regional level to promote best practices in utilization management.
- Facilitates quality improvement efforts by: conducting complex data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement, and leading efforts for improvement initiatives; facilitating the development and implementation of corrective action plans to address deficiencies, evaluate effectiveness, and track improvements in utilization review workflows/processes; actively adhering and influencing team members to adhere to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care; and developing, refining, and providing oversight for desk-level procedures (e.g., workflows).
- Facilitates 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 healthcare services, and providing expert guidance to team members for reviews; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to leadership, and recommending and/or instituting appropriate actions for high-risk member cases.
Job Tags
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