Out-Patient UM Clinician

Summary

Reporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities

· Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required

· Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:

o Promote improved quality of care and/or life

o Prevent hospitalization when possible and appropriate

o Provide for continuity of care

o Ensure appropriate levels of care are received by members

· Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business

· Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers

· Identify complex authorization requests and appropriately refer to Case Management personnel

· Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests

· Work effectively with all other sub team members within Outpatient UM

· Maintain prompt and open communication with Denial team to meet tight turnaround time (usually with 24hours of initial request)

· Communicate with Health Plan Liaisons in the event that a precertification requests requires health plan review, ensuring review is completed in compliance with timeliness standards

· Outreach to Provider Network Operations team to address provider related referral insufficiencies

· Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources

· Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.

· Maintain knowledge of UM policy and procedures

· Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians

Minimum Job Requirements

· Current California RN or LVN license

· 2+ years of experience in utilization management preferred

· Proficiency with Microsoft Office Programs; primarily Word and Excel

· EZ-CAP® knowledge a plus

Skill and Abilities

· Excellent relationship management skills with the ability to communicate effectively with all stakeholders

· Strong organizational, task prioritization, and delegation skills

· Ability to collaborate successfully with all levels of the organization