Health Services Spec, Utilization

Duration: 3 Months

Location: 100% Remote

Work Schedule: 8:00 a.m. 5:00 p.m. EST (flexible hours)

• Minimum 5 years of clinical nursing experience
• Background in critical care or managed care
• Prior knowledge of managed care and utilization review
• Proficiency with MCG guidelines
• Active compact RN license or Maryland RN license
• Strong knowledge of Microsoft applications
• Experience with both Facets and Guiding Care (mandatory)

• LPN license is acceptable

Utilizing key principles of utilization management the Utilization Review Specialist will perform prospective concurrent and retrospective reviews for authorization appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills the Utilization Review Specialist will analyze clinical information contracts mandates medical policy evidence-based published research national accreditation and regulatory requirements to contribute to the determination of appropriateness and authorization of clinical services both medical and behavioral health.

• 50% Determines medical necessity and appropriateness by referencing regulatory mandates contracts benefit information Milliman Care Guidelines Apollo Guidelines ASAM Medicare Guidelines Federal Employee Program and Policy Guidelines Medical Policy and other accepted medical/pharmaceutical references. Follows NCQA Standards Medical Policy all guidelines and departmental SOPs to manage member assignments. Understands all lines of business to include Commercial FEP and Medicare primary and secondary policies.
• 30% 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.
• 20% 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.

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Bachelors Degree

Education Details: Nursing

• 5 years Clinical nursing experience
• 2 years Care Management

In lieu of a Bachelors degree an additional 4 years of relevant work experience is required in addition to the required work experience.

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of clinical guidelines medical policies and accreditation and regulatory standards.
• Working knowledge of IT and Medical Management systems familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

• 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 Member 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 the appropriateness of member services and treatments on a case-by-case basis.

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
• LPN - Licensed Practical Nurse - State Licensure
• CNS-Clinical Nurse Specialist Preferred

Clinical UM expertise regulatory compliance knowledge experience in Guiding care platform.

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin age protected veterans or individuals with disabilities.