*This position requires a RN license.
The incumbent utilizes clinical judgement in providing utilization management services. The
focus is to provide high quality, cost-effective care which will enable patients to achieve
maximum medical improvement while receiving care deemed medically necessary. Assists in
determining appropriateness, quality and medical necessity of treatment plans using preestablished guidelines. This position may be assigned cases in long-term care and ancillary,
DME or medical services.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conducts retrospective claims review, either in the aggregate or on an individual basis.
Provides summaries of findings to the Team Manager UM.
- Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22,
Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies
and procedures for each product line.
- Recommends and coordinates interventions to facilitate high quality, cost-effective care,
monitoring treatment, progress and outcomes of patients.
- Documents and maintains patient-specific utilization management records in database
- Assists in the refinement/improvement of the HS programs. Participates in continuous
process improvement endeavors.
- Works with other PHC departments to resolve issues relating to authorization of medical
- Audits medical records as appropriate.
- Performs inter-rater reliability audits as directed by department manager.
- Elicits medical information from providers and medical records and applies clinical
judgement to determine medical necessity and provide timely reports/authorizations for
- Refers cases that do not meet criteria on to the PHC HS department manager, director or
Chief Medical Officer as appropriate.
SECONDARY DUTIES AND RESPONSIBILITIES
- Participates in special projects and assignments as required.
Education and Experience
RN/LVN with 2-3 years experience to include one (1) year managed
care (utilization management) experience; or equivalent combination of
education and experience. General knowledge of managed care with
emphasis in UM preferred.
Special Skills, Licenses and Certifications
Current California RN/LVN license. Strong knowledge of nursing
requirements in a clinical setting. Knowledge of utilization management
programs as related to use of pre-set criteria and protocols. Familiarity
with business practices and protocols with ability to access data and
information using automated systems. Ability to work within an
interdisciplinary structure and function independently in a fast-paced
environment while managing multiple priorities and meeting deadlines.
Strong organizational skills required. Effective telephone and computer
data entry skills required. Valid California driver’s license and proof of
current automobile insurance compliant with PHC policy are required to
operate a vehicle and travel for company business.
Performance Based Competencies
Excellent written and verbal communication skills with ability to read and
interpret benefit contract specifications. Ability to understand and follow
established criteria and protocols used in managed care functions.
Ability to formulate ideas and solutions into appropriate questions and
assess/interpret the verbal responses. Ability to apply clinical judgment
to complex medical situations and make quick decisions. Ability to
communicate effectively with coworkers, members, their families,
physicians, and health care providers.
Work Environment And Physical Demands
Daily use of telephone and computer for most of the day. Cubicle work
station. Ability to use a computer keyboard. Must be able to lift, move, or
carry objects of varying size, weighing up to 10 lbs.
All HealthPlan employees are expected to:
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.