Performs duties of Care Management Specialist as well as serving in a manager role for the Medical Management Team. Responsible
for processing various health plan appeals, developing clinical criteria, analyzing data, conducting audits and preparing reports. Serves as a resource to other team members.
- Coordinates appeals process, including logging various incoming appeals from providers and members, participating in appeal decision-making, researching and summarizing appeals for committee review and composing correspondence to communicate
requests for medical services.
- Develops and creates clinical criteria and authorization guidelines through literature reviews and related research; creates draft documents for medical director and committee review and approval. Revises and updates documents as necessary.
- Serves as resource to Medical Management Team members, providing guidance in day-to-day operations.
- Assists Director in various administrative responsibilities, including report development, coordinating staff meetings, conducting audits, analyzing data and providing input to Team member performance evaluations. Attends various Committee meetings as needed to represent Medical Management Team.
- Responsible for prior authorization process including logging of incoming prior authorizations from providers, reviewing documentation for decision and composing correspondence to communicate clinical decisions to parties involved.
- Completes special projects/other duties as assigned
- Performs clinical utilization review to determine medical appropriateness and cost-effectiveness of requested healthcare services. Researches cases and applies criteria and clinical judgment to evaluate and render determinations for authorization
- Collaborates with Medical Director in clinical decision making as applicable.
- Composes correspondence to members, providers and third-party administrator related to medical management, such as clinical determinations or requests for additional case detail.
- Facilitates claim adjudication process by assisting in claim analysis and providing information related to authorizations, COB, negotiated rates, etc.
- Assists with new program planning and development related to utilization management.
- Provides education, as needed to members, physicians, hospital and office staff regarding plan benefits, policies and procedures to facilitate utilization management processes.
- BS in Nursing required; must be a Registered Nurse licensed to practice in the State to Michigan
- Must have at least five years experience in medical management, utilization management or similar type of
- PPO/HMO background
- Ability to set priorities, organize work, gather, interpret and analyze clinical data and recommend medical services based on analysis
- Excellent verbal and written communication skills
- Demonstrates excellent interpersonal skills necessary to interact effectively with staff and customers of all levels, including physicians and administrators
- Good presentation skills
- Must demonstrate a strong commitment to exceeding customer expectations
- Proficient in the use of a computer; Microsoft Office Products usage preferred
Ascension Health - 2 years ago
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Ascension Health has ascended to the pinnacle of not-for-profit health care. As the largest Catholic hospital system in the US, and thus one...