Utilization Management Specialist (Home-Based) - Prior Authorization

Job Summary

Cover level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable workflows.

Responsibilities

• Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.
• Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control.
• Determines appropriate action for referring cases that do not meet departmental standards and requires additional secondary review and/or escalation as needed.
• Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services.
• Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization.
• Affixes to monitor the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria.
• Aids in report preparation, correspondence, and maintenance of appropriate records.
• Ensures services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements.
• Maintains working knowledge of payer standards for UM functions for authorization requirements.
• Assists the department in additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated.

Requirements

• Bachelor's degree in nursing preferred.
• Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
• Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing.
• Obtains and subsequently maintains required department specific competencies and certifications.

Qualifications

• Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed.
• Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services.
• Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals.
• Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization.
• Ensures services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements.
• Maintains working knowledge of payer standards for UM functions for authorization requirements.
• Assists the department in additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated.

Benefits

Sanford offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits.

Pay

$27.50 - $38.50

Schedule

Full time, 40.00 weekly hours

Department Details

Opportunity to work remote.

Featured

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