Under limited supervision, the Care Management Pre-Certification Specialist is responsible for SmartHealth pre-certification management which includes but is not limited to prior authorization of selected services, understanding benefit design, benefit schedules, plan definitions, claim adjudication rules, and associate communication. Responsible for processing various health plan appeals, developing clinical criteria, analyzing data and preparing reports.
- 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 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.
- 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.
- Collaborates with Medical Director in clinical decision making as applicable.
- Coordinates appeals process, including logging various incoming appeals from providers and members, participating in appeal decision-making and composing correspondence to communicate clinical decisions.
- Completes special projects/other duties as assigned.
- Composes correspondence to members, providers and third-party administrator related to 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 medical management processes.
- Promotes, exemplifies and supports the Ascension Health Core Values of Service of the Poor, Reverence, Integrity, Wisdom, Creativity, and Dedication.
This position requires an Associate's Degree in Nursing and candidate must be a Licensed Practical Nurse licensed to practice in the State to Michigan. Must have experience in medical management, utilization management or similar type of work. PPO/HMO background preferred.
-Ability to set priorities, organize work, gather, interpret and analyze clinical data and recommend medical services based on analysis.
-Good interpersonal and communication skills, verbal and written.
-Good presentation skills.
-Proficient in the use of a computer. Microsoft Office Products usage preferred.
Ascension Health is an Equal Opportunity Employer M/F/D/V
- Knowledge, Skills, and Abilities:
Ascension Health - 2 years ago
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...