Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources. Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services. May also manage appeals for services denied. May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts. May be responsible for day-to-day operations of a single or multiple IPA/IPOD and staff, and may serve as liaison with the local health plan to ensure continuity for IPA/IPOD members.
Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies. Evaluates and authorizes the medical necessity of inpatient and outpatient services. Notifies provider of recommended changes in level of care. Evaluates cases for quality of care and documents quality issues. Reviews medical necessity for more complicated or escalated pre-certification services. May participate or assist in the planning of team, UM/QM, PCP, IPA, and/or Health Plan meetings, on or off-site. May act as Team Lead. Serves as a subject matter expert on process improvement teams. May serve as trainer for department, new hires, and/or IPA staff. Participates in departmental projects as assigned.
Minimum: Current licensure as a Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), or a Registered Nurse (RN). At least three years clinical experience. Knowledge of ICD-9 and CPT Coding guidelines.
Preferred: Managed care experience. Four years experience in utilization review.
CIGNA - 20 months ago
With a significant position in the US health insurance market, CIGNA covers some 11.5 million Americans with its various medical plans. The...