Terms of Employment
- Contract, 12 months
- This position is fully remote.
Overview
Our client is seeking a Utilization Review Specialist to perform prospective, concurrent, and retrospective reviews focused on authorization, appropriateness of care determination, and benefit coverage, using key principles of utilization management. This role involves leveraging clinical expertise and critical thinking skills to analyze clinical information, contracts, mandates, medical policies, evidence-based research, and national accreditation and regulatory requirements. The Utilization Review Specialist will contribute to determining the appropriateness and authorization of clinical services, including both 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, 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.
- Make 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.
- 5 years of clinical nursing experience.
- 2 years of care management experience.
- Utilization management experience.
- In lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
- RN – Registered Nurse – State Licensure And/or Compact State Licensure or LPN – Licensed Practical Nurse – State Licensure.
- Knowledge of Milliman Care Guidelines.
- Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
- Must have strong assessment skills with the ability to make rapid connection with members telephonically.
- Must be able to work effectively with large amounts of confidential member data and PHI.
- Must be able to prioritize workload during heavy workload periods.
- Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
- Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
- Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis.
Preferred Skills & Experience
- Working knowledge of managed care and health delivery systems.
- CNS-Clinical Nurse Specialist
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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