Spec, Utilization Management

About the role

The Utilization Review Specialist at Ampcus Inc. plays a crucial role in ensuring that clinical services are appropriately authorized and covered under various insurance plans. This position requires a combination of clinical expertise, regulatory compliance knowledge, and strong communication skills.

Responsibilities

• Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, and other accepted medical/pharmaceutical references.
• Follows NCQA Standards, Medical Policy, all guidelines, and departmental SOPS to manage member assignments.
• Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
• Conducts research and analysis of pertinent diseases, treatments, and emerging technologies to support decisions and recommendations.
• Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
• Applies sound clinical knowledge and judgment throughout the review process.
• Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities.
• Affords assistance to members and providers for alternative settings for care.
• Researches and presents educational topics related to cases, disease entities, and treatment modalities to interdepartmental audiences.

Qualifications

• Education: Bachelor's Degree in Nursing or related field.
• Experience: 5 years of clinical nursing experience, 2 years of Care Management Clinical Utilization Management expertise, regulatory compliance knowledge, and experience in Guiding care platform.
• Licenses/Certifications: RN - Registered Nurse - State Licensure and/or Compact State Licensure upon hire required, LPN - Licensed Practical Nurse - State licensure preferred.
• Preferred Qualifications: Working knowledge of managed care and health delivery systems, thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards, working knowledge of IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Skills and Abilities

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
• Strong assessment skills with the ability to make rapid connections with Members telephonically.
• Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards.
• Sound clinical knowledge and judgment throughout the review process.
• Prioritizes workload during heavy workload periods.
• Advanced analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
• Expertise in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint.

Benefits

Ampcus Inc. is committed to providing a comprehensive benefits package to its employees, which includes:

• Health Insurance
• Retirement Plans
• Flexible Spending Accounts
• Employee Assistance Programs
• Professional Development Opportunities

Pay

The salary range for this position is $60,000 - $80,000 annually, depending on experience and qualifications.

Schedule

This is a full-time position with standard business hours.

Equal Opportunity Employer

Ampcus Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.