Utilization Manager

Utilization Manager
Company:

American Academy Of Physician Assistants


Utilization Manager

Details of the offer

Description
Position Description
Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. As a Utilization Management Nurse at UnitedHealth Group, you will make sure our health services are administered efficiently and effectively. You'll assess and interpret member needs and identify solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization. Ready to make an impact?
The Utilization Manager (UM) is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. The UM also ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, procedures, diagnostics as well as appropriateness of treatment. Will also partner with medical director to interpreting appropriateness of care and accurate claims payment.
Primary Responsibilities:
Care coordination or discharge planning for appropriateness of treatment setting

Identify, request and/or obtain additional clinical and/or non-clinical information as needed to make an appropriate determination for medical claims

Ensure or audit to ensure? cases meet applicable clinical and/or administrative criteria, as defined by relevant references/resources (e.g.WTC HP Codebooks and policy manuals, CMS Guidelines, coding manuals)

Identify cases which warrant assignment to Medical Directors, forward as needed, and review the outcome of their determination

Perform initial assessment of appeals cases to determine next steps

Make determinations for administrative cases at the nurse level about whether the appeal should be approved or denied, based on available analyses/research of applicable information

Take appropriate steps based on case determination by the Medical Director or nurse (e.g., denial upheld, overturned, dismissed, pended for additional action)

Ensure that members/providers obtains a full and fair review of their appeal or grievance (e.g., by requesting, obtaining, documenting and/or communicating pertinent information for case files)

Document final determination of appeals or grievances using appropriate platforms, templates, communication processes, etc.

Communicate determinations to relevant stakeholders, as applicable (e.g., appellants, providers)

Reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, as it relates to the WTC contract

Responsible for completing prior authorizations as it relates to the WTC contract

Exercises independent judgment and decision making in determining appropriate treatment avenues (Code request)

Completion of applicable code requests as a result from a denied claim

Demonstrate understanding of business implications of clinical decisions to drive high quality of care

Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS,NCQA/URAC accreditation)

Ask critical questions to ensure member- and customer-centric approach to work

Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed

Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results

Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes

Use appropriate business metrics to optimize decisions and clinical outcomes

Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:

Associate degree in Nursing degree or higher nursing degree

Current license or able to obtain RN licensure in Texas
Minimum of 2 years acute care clinical experience

Familiarity with ICD10 coding

Utilization Management Experience

Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Experience with Outpatient Nursing (i.e. Durable Medical Equipment, Home Care, Physical Therapy, Occupational Therapy, Speech Therapy)

Must have knowledge of medical management process and ability to interpret and apply member benefits as it relates to the contract.

Must be able to problem solve in a fast paced environment, multitask, and meet tight deadlines

Ability to perform detailed work with a high degree of accuracy

Preferred Qualifications:

MedNet experience

Prior managed care experience strongly preferred

Understanding of regulatory standards and WTC contract requirements

Knowledge of analyzing and reporting statistical data a plus

Join us and discover how a superior professional environment and incredible opportunities make a difference in the lives of patients. We're a place where leaders thrive, and innovation abounds. Seize this opportunity to achieveyour life's best work.(sm)
Careers with LHI. Our focus is simple. We're innovators in cost-effective health care management. And when you join our team, you'll be a partner in impacting the lives of our customers, and employees. We've joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We're located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We're supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life's best work.SM
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment
Job Keywords: Utilization Manager, LHI World Trade Center Program, La Crosse, WI, Wisconsin
Job Information
Job ID:ba5122c0-10351720452

Location:
La Crosse, Wisconsin, United States

Requirements

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