Responsible for the effective and sufficient support of all utilization management activities to include prospective/pre-certfication review of the outpatient medical services for medical necessity and appropriateness of setting according to established policies. Using an established set of criteria, evaluates and authorizes the medical necessity of outpatient services.
Evaluates cases for quality of care and documents quality issues, issues letter to provider if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.
Responsible for steering members to in-network providers when possible.
Maintaining accurate system documentation and meeting documentation requirements established by department. Using multiple computer systems to complete their work.
Location: Travel throughout Tarrant County completing home assessments with members for personal attendant services (bathing, dressing, cleaning).
Must have current licensure as a Licensed Practical Nurse or Licensed Vocational Nurse with no restrictions or be a Masters degree Social Worker
Must have one year of utilization review experience plus three years clinical experience. Home health experience ideal.
Prefer managed care experience and knowledge of ICD-9, CPT coding, and Medicaid.
Good communication, organization and written skills required.
Good interpersonal skills and team oriented.
Strong computer skills required with MS Office products.
Ability to work in a busy, high-volume environment.
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