The Utilization Management (UM) Clinician, Senior Care Options (SCO) is responsible for the management of authorization requests for services to be rendered to the Plan’s SCO members, including both prior authorization of services, where required, and concurrent review of inpatient stays.

KEY FUNCTIONS/RESPONSIBILITIES:

• Adjudicates prior authorization and retrospective requests, either auto-approving those submitted by SCO Care Management staff or evaluating the medical necessity of requests submitted by providers by utilizing InterQual® or internally developed clinical criteria, collaborating, as necessary, with SCO Care Management staff and Medical Directors.
• Enters requests for or notifications of inpatient admissions into the clinical documentation system.
• Evaluates the medical necessity of continuing acute inpatient stays and acute rehabilitation and skilled nursing stays utilizing InterQual® and Truven criteria.
• Collaborates with facility staff, member’s PCP, Plan Medical Directors, SCO Care Management staff, and others regarding management of members not meeting continuing stay criteria. 
• Anticipates member’s post-discharge needs, managing transition of care or referring to SCO Care Management, per Plan policy and procedure.
• Completes member and provider notifications, citing clinical criteria and Medical Director denial rationale, when indicated. 
• Maintains mandated timeframes, including those related to fast-track appeals, and quality standards.
• Maintains current knowledge of medical necessity criteria, SCO benefits, the Plan’s utilization related policies and procedures, etc.
• Collaborates regularly with the SCO UM Leadership team, Plan Medical Directors, SCO  Care Management team members, members’ PCPs, requesting providers, and facility care management staff.
• Collects, analyzes, and reports productivity, quality, and outcome data and identifies opportunities for improvement; collaborates with SCO UM Leadership, SCO Care Management team, including SCO CM Leadership, and others to implement approved changes.
• Collaborates with SCO operations team regarding impact of utilization management policies and procedures on other operational areas, such as Claims; participates in SCO SWOT meetings, as requested.
• Identifies opportunities for process and policy improvement.
• Other duties as assigned.

QUALIFICATIONS:

EDUCATION:

• Nursing degree or diploma required; Bachelor’s Degree in Nursing (BSN) preferred
• Master’s Degree in Nursing or related field preferred
• Certified Coding Professional (CPC) or other medical coding certification preferred

EXPERIENCE:

• 5 years Registered Nurse experience, including 2 years direct care services and 3 years of any combination of utilization management, discharge planning in an acute care setting or care coordination

PREFERRED/DESIRABLE:

• 2 years health plan operations experience with Medicare and/or Medicaid populations, Senior Care Options population highly desirable
• Health plan operations, experience interacting with providers highly desirable
• Knowledge of or experience with LTSS and/or community support services
• Acute care experience

LICENSURE, CERTIFICATION OR CONDITIONS OF EMPLOYMENT:

• Active unrestricted RN License
• Ability to take after hours call, including evening/nights/weekends

COMPETENCIES, SKILLS, AND ATTRIBUTES:

• Strong oral and. written communication skills
• Ability to interact within all levels of the organization as well as with external parties
• Strong working knowledge of Microsoft Office products.
• Demonstrated organization and time management skills
• Strong analytical and clinical problem solving
• Ability to prioritize work
• Detail oriented

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience