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Posted: Monday, March 13, 2017 1:14 PM

Requisition Number 16-0133 Post Date 11/7/2016 Title Utilization Management Nurse City Lubbock State TX Description SUMMARY:Reviews clinical information to make accurate medical necessity decisions for services requiring prior authorization (eg elective admissions, surgeries, diagnostic procedures & treatments, drugs on the medical benefit, durable medical equipment and other services requiring prior authorization) using approved medical criteria and regulatory guidelines. Promotes delivery of services in appropriate settings by reviewing clinical information and making accurate medical necessity decisions and level of care determinations for inpatient care using approved medical criteria and guidelines.ESSENTIAL DUTIES and RESPONSIBILITIES:a€ cents Maintains current knowledge of approved utilization management criteria and guidelines as well as Evidence of Coverage, Certificate of Insurance, and Schedule of Benefits requirements and pertinent regulations.a€ cents Makes accurate and consistent authorization determinations, including collecting appropriate clinical information, applying appropriate medical criteria, consulting with Medical Director, and communicating authorization determinations to providers and members in accordance with policy and procedure and within timeliness requirements.a€ cents Researches and obtains records of medical necessity and appropriate clinical diagnostics and documentation for requested services when records are needed to complete the determination process.a€ cents Reviews all potential denials and refers all medical necessity denials and out-of-network requests to Medical Director for final determination. Provides support when needed to give input to LVN reviewers, or to perform an RN review on a complex request originating with an LVN.a€ cents Composes denial explanations for members in terms that are easy for a lay person to understand.a€ cents Guides Members to in-network providers. Provides transitional authorizations within department guidelines. Proactively works to support a safe plan for discharge to the most appropriate level of care by working with facility colleagues (case managers, discharge planners, social workers, or UR/QI personnel and physicians) in order to assure appropriate utilization of benefits.a€ cents Identifies and refers at-risk members to FirstCare case and disease management programs, as well as relevant community services and agencies.a€ cents Authorizes and enters data of services for payment of claims, using appropriate fee schedules/contracted and/or MOU rates.a€ cents Collaborates closely with Medical Directors and Case Management on members with high-cost or complex needs, and on member needing coordination of UM and CM needs.a€ cents Participates in quality initiatives, such as case reviews, interrater reliability testing, audits, and continuous process improvement.a€ cents Develops competency in targeted cross-training skills in order to promote operational efficiency. Requirements EDUCATION AND EXPERIENCE, SKILLS, CERTIFICATES, LICENSES, AND/OR REGISTRATIONS:a€ cents Bachelor degree or may substitute with 4 years like experiencea€ cents Must have RN license current in the State of Texas.a€ cents 2 years performing same or similar responsibilities or having related experience in the managed/health care industry, including: clinical judgment, customer service experience, and experience in applying criteria to make authorization determinations.FirstCare Health Plans is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetics or any other basis prohibited by law. .


• Location: Lubbock

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