UTILIZATION REVIEW - AC COM UT

Aultcare Corp. - Canton, OH

Posted: 2/18/2024 - Expires: 5/18/2024

Job ID: 269923363

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Job Description

Req# 28147

Aultman Health Foundation, CANTON, OH

AULTCARE ADMINISTRATION

Aultman Health Foundation

Full Time, Day Shift, 8-4:30

PURPOSE OF POSITION:

The primary purpose of the Utilization Review RN Care Manager is to utilize medical necessity criteria to make/support decisions regarding the appropriateness of requested procedures, treatments, therapies, and diagnostic procedures for pre-authorization, concurrent review, and retrospective review of inpatient and outpatient services. The Utilization Review RN Care Manager applies medical necessity criteria to support a clinical rationale for care decisions, promote clinical quality, and the cost-effective use of medical resources. Collaborates with Care Coordination staff members, Physicians, and Financial team staff members to review services requested, and provide feedback to the ordering provider if desired services do not meet the medical necessity criteria. Actively participates in on-going efforts to identify and educate providers regarding evidence-based and cost-effective alternatives for care delivery.

RESPONSIBILITIES & EXPECTATIONS:

Gathers relevant information accurately and systematically.
Performs reviews thoroughly with high attention to detail, including incomplete requests that have been previously managed by other staff.
Reviews documentation of member needs and processes or obtains authorizations based on clinical criteria, payer contracts and custom plan language including narrowed and tiered networks.
Applies Utilization Management policies that result in cost-efficient utilization of services
Identifies medical necessity criteria discrepancies and forwards to physician reviewers in a timely manner to receive certification determination and/or physician-to-physician communication.
Communicates with members and providers telephonically about network capabilities and how the member's needs can be most appropriately met.
Advocates for member to receive timely care at most appropriate place of service
Generates approval and denial letters as directed by the Director, Supervisor or Medical Director, appropriately incorporating the specific clinical criteria and plan language utilized to arrive at determination.

Learn and utilize tools and processes to perform and properly track all utilization reviews, as well as refer members to further care engagement and stop loss when needed (i.e. catastrophic illness) to ensure that members are receiving appropriate medically necessary services covered by the plan.
Other duties as assigned (i.e. employer-group specific reporting, assistance with administrative case audits, perform audit data validation, etc.).
Anticipates and follows through with both internal and external customer requests to their satisfaction.

Meets departmental and regulatory turnaround time requirements.

Maintains confidentiality of enrollee and employer information at all times.
Complies with policies, procedures and code of conduct, Ohio Nurse Practice Act, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other governing and accrediting bodies.
Seeks supervisory guidance/approval as appropriate.

Customer Service/Satisfaction

Anticipate and follow through with both internal and external customer request to their satisfaction. Seek assistance of others and other departments when needed.
Maintain cooperative approach in dealing with co-workers, creating productive working relationships.

Be flexible and willing to change.
Keep lines of communication open.

Express ideas and information verbally and in writing using appropriate grammar, word usage and organization of ideas clearly and concisely.
Deal with a diversity of people in a broad range of circumstances.
Communicate with customers in a professional manner and maintain positive contact with others including but not limited to co-workers and any other medical professionals.

Dependability/Reliability

Accept assignments willingly and ensures through completion of assignments meeting deadlines.
Adapt to changes in unplanned workload and job demands while paying attention to detail.
Seek additional assignments upon completion of own duties as time allows.
Meet acceptable attendance and punctuality expectations. (Three or less occurrences per year is acceptable - excluding any FMLA.)
Participate in orientation of new personnel as requested and across product lines if necessary.
Make appropriate recommendations for changes in day-to-day operations.
Handle difficult and sensitive issues with tact, exercise judgment where necessary and consult Director or Supervisor on major problems and issues.
Demonstrate initiative in problem solving; knows when to seek counsel of Nursing staff and/or Coordinator.
Complete special projects as assigned
Promote and demonstrate professional standards to enhance the development of the department.
Keep within acceptable limitations for break and lunch schedules.
Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.

Ethical Conduct

Maintains AultCare standards of confidentiality, including HIPAA privacy guidelines of member/employer information at all times.

Comply with policies, procedures at all times.
Take responsibility for own actions.
Demonstrate honesty and integrity in all functions and relationships.

Continuous Quality Improvement

Maintain superior quality in all job functions, contributing to the successful attainment of departmental/organizational quality goals.
Respond positively to change and new ideas.
Identify and suggest to the appropriate supervisory staff ideas for quality improvement in departmental operations with the goal of improving efficiency and productivity.
Actively seek out opportunities to make a contribution, rather than passively accept situations.
Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed.

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and are not a detailed description of all the work requirements that may be inherent to this position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.

AultCare/AHF will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on AultCare/AHF or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the AultCare Human Resource Department and request such an accommodation.

QUALIFICATIONS:

Education: Graduate of an approved School of Nursing with a minimum of 4-5 years' experience. Healthcare experience in Managed Care preferred.
Has a working familiarity with the Utilization Management standards of the National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS).
Has a working familiarity with appeals processing and associated standards and regulations.
Maintains current unrestricted RN licensure in State of Ohio.
Demonstrates willingness to become certified in Managed Care Nursing (CMCN).
Demonstrates strong communication (written and verbal), problem-solving and analytical skills.
Experience with Microsoft Word, including Outlook, Word, Excel and PowerPoint and has strong technological adaptability.

WORKING CONDITIONS:

Hours of operation are 7:00 am to 5:00 pm, Monday through Friday, shifts as assigned. Occasional overtime, on-call, off-shifts (evenings and/or weekends) scheduled as necessary.
Office environment with moderate noise level.
Frequent sitting, use of hands/fingers across keyboard or mouse.
Occasionally walking, standing, twisting/turning and reaching upward or forward during workday.

AultCare is an Equal Opportunity Employer (EOE) that values and respects the importance of a diverse and inclusive workforce. It is the policy of the company to recruit, hire, train and promote persons in all job titles without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, protected veteran status or disability. We recognize that diversity and inclusion is a driving force in the success of our company. AultCare is an Equal Opportunity Employer that will make reasonable accommodation to enable individuals with disabilities to apply and compete for employment opportunities for which they are qualified. To request an accommodation, please email our Human Resources department at kbricker@aultcare.com , or call 330-363-6388, for further assistance.

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Job Summary

Employment Type:: Full Time Employee
Job type:: Federal Contractor
Skill Based Partner:: No
Education Level:: No school grade completed
Work Days:: Mon, Tue, Wed, Thu, Fri
Job Reference Code: 78277162
Salary: N/A
Licenses / Certifications:: N/A; Applied Math: 4; Graphic Literacy: 4; Workplace Documentation: 4

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UTILIZATION REVIEW - AC COM UT

Aultcare Corp. - Canton, OH

Job Description

Job Summary