Utilization Review Coordinator/ Medical Policy Coordinator
Job ID: : 25805
Department: : Health Plan QUI
City: : Bloomington, MN
Location: : HP - Bloomington 8170 Office Bldg
Position Type: : Full-Time
Anticipated Work Schedule: : Monday through Friday, 8:00am - 5:00pm
Hrs/Pay Period: : 80
Job Description: :
The culture at HealthPartners is one of ownership, pride, service, and most importantly, partnership. That spirit of partnership among employees, and with patients and the community is just one of the many reasons we were recently named one of the Twin Cities best places to work by the Minneapolis/St. Paul Business Journal. Join us for a career that offers respect, support and encouragement. You’ll stay for the power of partnership.
We are currently seeking an experienced RN (prefer BSN) for a Utilization Review Coordinator/ Medical Policy Coordinator position. This individual will be responsible for:
1. Authorizations in prospective, concurrent review, retrospective review and ongoing management for outpatient/inpatient medical, mental health, chemical health, home health care and skilled nursing facilities.
2. Researching, reviewing and making timely coverage recommendations based on medical appropriateness, for all products, while maintaining the integrity of each product line.
3. Applying clinical skills and expertise in conjunction with established medical criteria, member eligibility and benefit coverage information, in the review of prior authorization requests, to ensure high quality, cost effective care.
4. Maintaining a thorough and comprehensive understanding of regulations, member contracts, product lines, HealthPartners policies and procedures in order to serve as a resource for providers, members and internal departments.
5. Analyzing and evaluating technologies and developing coverage criteria to be used for benefit determinations.
6. Serves as subject matter expert on complex medical management issues for internal and external customers.
Monday through Friday, 8:00am - 5:00pm
1. Currently licensed Registered Nurse.
2. Minimum of three years clinical practice experience as an RN in medical/surgical, critical care, home care, or equivalent knowledge of current hospital and clinical care processes.
3. Excellent nursing assessment skills
4. Excellent verbal and written communication and interpersonal skills.
5. Excellent problem identification and solving skills.
6. Ability to organize and prioritize multiple assignments within workload
7. Ability to function independently and take independent action, within the scope of job responsibilities.
8. Competency in personal computer skills including Microsoft word, Outlook and Internet.
1. Responsible for assessing, monitoring and authorizing services for inpatient, outpatient, home health care and skilled nursing facilities utilizing thorough knowledge of multiple criteria sets and products.
2. Responsible for making coverage determinations and communicating relevant information to physicians, providers and members to facilitate utilization management, coordination of care and assist in the claims adjudication process.
3. Responsible for providing member specific utilization management and facilitate discharge planning based on needs of member with attention to complex cases to include communication between physician, family, social services, providers and vendor to result in appropriate resource utilization while maintaining quality and continuity of care.
4. Responsible for coordinating medical/mental health care between networks, in-plan/out-of-plan contracts.
5. Responsible for preparing documentation and consulting with the Medical Director for all potential denials of an admission, continued stay or outpatient service that does not meet medical necessity or HealthPartners criteria. Decision for denial is within the Medical Director role.
6. Responsible for accurately interpreting and correctly applying benefits, networks and product variances and clearly communicating such to members, providers and internal departments.
7. Acts as a liaison between internal and external customers; Marketing, Sales, Claims, Member Services, Nurse Navigators and clinics to resolve systems/process issues.
8. Collaboratively define implementation plans for compliance with regulatory Utilization Management requirements, policies and procedures.
9. Responsible for determining medical necessity, appropriateness and effectiveness of services requested using established medical coverage criteria and guidelines, contacting appropriate physician consultants and medical directors as appropriate.
10. Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to appeals of “urgently needed, not yet rendered services” in compliance with state regulations.
11. Responsible for producing consistent, sound and defensible coverage decisions, according to established departmental and policies and procedures.
12. Efficiently and accurately communicate coverage decisions to members, providers and medical groups, following timelines established by regulations and accreditory standards.
13. Thorough understanding of Health Plan’s infrastructure and ability to apply this knowledge to coordinate all aspects of decision making needed to complete complex reviews.
14. Evaluate and analyze available literature on new and existing technologies to determine safety and effectiveness. Coordinate and facilitate input from physician consultants and other resources (i.e., Sales & Marketing, Legal etc.). Summarize information and present to Medical Director for coverage decision.
15. Review and edit responses to Member Appeals and MDH (Minnesota Department of Health) inquiries as requested by the Appeals area.
16. Organize and present in-services and orientation sessions for new and existing customers on coverage policies and medical review process.
17. Ability to abstract pertinent clinical findings and appropriately apply to corresponding clinical criteria.
18. Identify and appropriately inform Manager and Supervisor of sensitive or complex cases.
19. Evaluate, research, and update coverage criteria as assigned.
20. Requires thorough knowledge of state and federal regulatory statutes, accreditation standards and primary care contracts as they pertain to shared risk with plan.
21. Able to negotiate, resolve or redirect when appropriate issues pertaining to differences in expectations of coverage, eligibility and appropriateness of treatment recommendation.
22. Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and member contracts in order to ensure compliance.
23. Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors managed care offices and other customers.
24. Maintain confidentiality of case information.
25. Other duties as assigned
HealthPartners is nationally acclaimed for providing outstanding patient care and we offer an excellent salary and benefits package. For more information and to apply go to www.healthpartners.jobs and search for job ID 25805.
Health is what we do. Partnership is how we do it.
HealthPartners - 10 months ago