Terms of Employment
- Contract, 12 Months
- This position is primarily remote. With that said, candidates must reside within the DC, Maryland, Virginia area for onsite training and “All Hands” meetings.
Overview
Our client seeks a Utilization Management Specialist who, using key principles of utilization management, will perform prospective, concurrent, and retrospective reviews to determine authorization, appropriateness of care, and benefit coverage. By leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based research, and national accreditation and regulatory requirements to assess the appropriateness and authorization of clinical services, including medical and behavioral health care.
Responsibilities
- Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials, Gov, National Institute of Health, etc.).
- Follows NCQA Standards, Company Medical Policy, all guidelines and departmental SOPS to manage their 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, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
- 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.
- Follows member contracts to assist with benefit determination.
- Makes appropriate referrals and contacts as appropriate.
- Offers assistance to members and providers for alternative settings for care.
- Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.
Required Skills & Experience
- Bachelor’s Degree in Nursing and 5 years of clinical nursing experience.
- 2 years of care management experience.
nTech is an equal opportunity employer. All offers of employment are contingent upon pre-employment drug and background screenings. Only candidates who meet all of the above client requirements will be contacted by a recruiter.
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