utilization management specialist

BRADFORD HEALTH SERVICES

<div><p><b>About Company:</b></p><p></p><p>
We&rsquo;re officially a <b>Great Place To Work&reg;</b>! We&rsquo;ve always believed that supporting our team is just as important as supporting our patients. Now, we&rsquo;re proud to share that we&rsquo;ve earned Great Place To Work&reg; Certification - based entirely on feedback from our own employees.</p><p>
Read more here: https://ow.ly/YQ1C50WuRH1</p><p>
This certification reflects the culture we&rsquo;ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.</p><p>
At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.</p><p>
Our benefits include:</p><ul><li><p><b>
Medical Coverage</b> &ndash; Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.</p></li><li><p><b>
Expanded Coverage</b> &ndash; Options for domestic partners and a wider network of in-network providers.</p></li><li><p><b>
Mental Health Support</b> &ndash; Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.</p></li><li><p><b>
Voluntary Coverages</b> &ndash; Pet insurance, home and auto insurance, family legal services, and more.</p></li><li><p><b>
Student Loan Repayment</b> &ndash; Available for nurses and therapists.</p></li><li><p><b>
Retirement Benefits</b> &ndash; 401(k) plan through Voya to help employees plan for the future.</p></li><li><p><b>
Generous PTO</b> &ndash; A robust paid time off policy to support work-life balance.</p></li><li><p><b>
Voluntary Benefits for Part-Time Employees</b> &ndash; Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.</p></li></ul><p>
At Bradford Health Services, we don&rsquo;t just invest in our patients&mdash;we invest in our people.</p><p></p><p><b><br>
About the Role:</b></p><p>
The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.</p><p><b>
Minimum Qualifications:</b></p><ul><li>
Bachelor&rsquo;s degree in a healthcare or related field.</li><li>
At least 2 years of experience in utilization review, case management, or clinical healthcare roles.</li><li>
Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.</li><li>
Familiarity with insurance authorization processes and healthcare reimbursement models.</li><li>
Excellent analytical, communication, and organizational skills.</li></ul><p><b>
Preferred Qualifications:</b></p><ul><li>
Experience with electronic health records (EHR) systems and utilization management software.</li><li>
Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).</li><li>
Prior experience working with managed care organizations or insurance companies.</li><li>
Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.</li></ul><p><b>
Responsibilities:</b></p><ul><li>
Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.</li><li>
Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.</li><li>
Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.</li><li>
Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.</li><li>
Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.</li></ul><p><b>
Skills:</b></p><p>
The Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.</p></div>

Utilization Review Specialist

Montage Health

<div><div>Welcome to Montage Health&rsquo;s application process!</div><div>
Job Description:</div><div>
The Clinical Pharmacy Specialist will perform duties in the following areas across all lines of business, including Utilization Management, Formulary Support, Appeals and Grievances, and Audit and Reporting Support to support the pharmacy team.</div><div></div><div>
This position will perform duties reviewing coverage for medications under the pharmacy and medical benefits for all lines of business necessary. The Clinical Pharmacy Specialist utilizes established company guidelines to review requests from physicians, medical groups, pharmacies, and members for the utilization of prescription drugs and pharmacy benefits. The specialist will conduct, research, and resolve any inquiries, problems, or issues in a timely manner.</div><div></div><div>
The Clinical Pharmacy Specialist is responsible for supervising and directing the support services needed for pharmacy services across all lines of business. This team member will continuously look for ways to improve processes and contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner.</div><div></div><div>
Responsibilities</div><div>
Utilization Management: Prior Authorization for Medical and Pharmacy Benefit (Medicare Part B and Part D; Commercial Plans)</div><ul><li>
Input, review and decision Medicare Part B requests for J codes, Q codes, and other medical benefits drugs/supplies.</li><li>
Track and triage coverage determinations and/or prior authorization requests submitted from providers and determine if a pharmacist review is required.</li><li>
Monitor prior authorization system to ensure turnaround times are met and contact providers for additional information to facilitate coverage determination reviews.</li><li>
Refer coverage determination requests for specialty drugs to a delegated vendor or client for processing when applicable.</li><li>
Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.</li><li>
Notify physicians, providers, and members of coverage determination request decisions.</li><li>
Oversight and preparation of correspondence, proposals, reports, spreadsheets, and forms.</li><li>
Assist in maintaining policies &amp; procedures, including editing, proofreading.</li><li>
Provide project management assistance to pharmacist and team as needed.</li><li>
Support member and provider calls regarding authorization, benefit inquiries, and resolution of pharmacy-related member questions as well as outbound customer service calls to members and delegated partners.</li><li>
Coordination and completion of intake/processing for pharmacy and medical authorization and appeal requests. Perform preliminary review for completeness and appropriate documentation. Triage and escalate to the appropriate clinical resource when needed.</li><li>
Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/consultation by a pharmacist.</li><li>
Support the pharmacist or Pharmacy Director with quality and STARS related measures, including outreach to members, providers, and pharmacies.</li></ul><div></div><div>
Formulary Support</div><ul><li>
Assist the Director in maintenance of the formulary and processing formulary change requests on a weekly basis.</li><li>
Support team in generating, maintaining, and reviewing Formulary Status Grids.</li><li>
Assist pharmacist in audits and quality checks on the current formulary status for accuracy and contract compliance.</li></ul><div></div><div>
Appeals and Grievances</div><ul><li>
Responsible for intake/entry and investigation/resolution of all prescription-related grievances received by the Plan or PBM</li><li>
Identify validity of appeal and send request to correct department as appropriate.</li><li>
Other appeal tasks as required.</li></ul><div></div><div>
Audit and Reporting Support</div><ul><li>
Assist pharmacist in a range of tasks necessary for pharmacy audit and recovery functions, including:<ul><li>
Perform audits and quality checks on active prior authorizations claims.</li><li>
Review paid claims for quantity and/or billing discrepancies.</li><li>
Investigate member complaints and documentation of findings according to Fraud Waste and Abuse (FWA) program.</li></ul></li><li>
Support pharmacist in monitoring delegated PBM functions through generation of reports and the review of reports such as daily rejected claims, in depth monthly review of approved and rejected claims, monthly review of posted/published formulary, monthly review of redeterminations and prescription related grievances, and Coverage Gap Discount discrepancy reports.</li><li>
Communicate or fax inquiries to pharmacies related to review findings and updates pharmacy database with incoming phone calls, faxes, and e-mails.</li><li>
Responsible for the maintenance of consistent processes and updating of policies and procedures and standard operating procedures as assigned.</li><li>
Assist pharmacist with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)</li><li>
Medicare Part D Operations, including:<ul><li>
Assist with identifying and correcting eligibility and group issues.</li><li>
Process member claims and pharmacy claims.</li><li>
Review and process Medicare Advantage Prescription Drug Event (PDE) data, such as:<ul><li>
Identification of errors with member eligibility, Low Income Subsidy Cost Sharing, as well as processing Institutional, ESRD and Hospice prescription drug claims.</li><li>
Monitor and report prescription drug metrics, including but not limited to, review of B versus D drugs, appropriate Copay and Deductible calculation, and corrective actions for informational and rejected PDE claims.</li></ul></li></ul></li></ul><div></div><div>
Other Responsibilities</div><ul><li>
Serve as a training resource for other team members and identifies and shares best practices.</li><li>
Provide administrative support to the Pharmacy Director for Committees chaired by Chief Medical Officer.</li><li>
Assist with pharmacy matters across all lines of business.</li><li>
Develop professional relationships with physicians, physician&rsquo;s office staff, medical management staff and/or pharmacists.</li><li>
Demonstrate understanding and accurate interpretation to support compliance with regulatory standards, e.g. Medicare Advantage and HIPAA.</li><li>
Prioritize and plan work for completion in a timely manner, coordinating with others as needed, and meeting deadlines set for all phases of work.</li><li>
Maintain a high level of professionalism, safeguarding and preserving the confidentiality of all information in accordance with HIPAA regulations.</li><li>
Demonstrate the ability to adapt to changes in the workload and responsibilities.</li><li>
Perform other activities and functions related to pharmacy or UM as delegated by the pharmacist or Pharmacy Director to evolve with business needs.</li></ul><div></div><div>
Experience</div><ul><li>
Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.</li><li>
Integrity: Consistently honors commitments and takes responsibility for actions and words.</li><li>
Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.</li><li>
Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.</li><li>
At least three years of experience in a health plan or PBM performing prior authorization for drugs, particularly Medicare Part B and Part D.</li><li>
Attention to details in obtaining complete and accurate information.</li><li>
Ability to key data accurately and efficiently.</li><li>
Ability to communicate effectively, including written and verbal communication skills.</li><li>
Bilingual in English and Spanish preferred.</li><li>
Business English and/or technical vocabulary related to health care industry (insurance/medical terminology).</li><li>
Basic knowledge of medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-10, CMS 1500, etc.).</li><li>
Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.</li><li>
Excellent phone manner and ability to handle multiple phone lines.</li><li>
Ability to identify and trouble-shoot problematic issues independently.</li><li>
Ability to follow clinical criteria and instructions to approve prior authorization requests.</li><li>
Must be able to meet established deadlines.</li></ul><div></div><div>
Education</div><div>
Minimum A.A. degree</div><div></div><div>
Licensure/Certifications</div><div>
License/Certification: Active Pharmacy Technician License required.</div><div></div><div>
Pay Rate: $30 per hour</div><div></div><div>
Equal Opportunity Employer</div><div></div><div>
Assigned Work Hours:</div><div>
Full time (remote)</div><div></div><div>
Position Type:</div>
Regular</div><div></div>

Clinical Pharmacy Specialist - Aspire Health

Spartanburg Regional Healthcare System

<div><b>Job Requirements<br>
</b><br>
<p><b>Position Summary</b></p><p></p><p><br>
Under the supervision of the Manager, the Case Manager (CM) has knowledge and skill in the areas of discharge planning, transitions of care, utilization management (UM), medical necessity, and patient status determination. The CM facilitates effective processes based on the regulatory and reimbursement requirements of various commercial and governmental payers. The CM assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. They provide cost-effective services while maintaining quality care through collaboration with health care providers to coordinate the transition of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement. The CM performing utilization management (UM) provides the critical function of obtaining certification and approval of the patient&rsquo;s hospital stay as required by the payer.</p><p></p><p><b><br>
Minimum Requirements</b></p><p></p><p><b><br>
Education</b>
</p><ul><li>Graduate of an accredited school of nursing, Bachelor&rsquo;s Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW)</li></ul><p><b>
Experience</b>
</p><ul><li>1-3 years healthcare experience or 1-3 years Case Management experience (Care Coordination, Transitions of Care or Utilization Management)</li></ul><p><b>
License/Registration/Certifications
</b></p><ul><li>Current R.N. licensure in the state of SC or Current Social Work licensure in the state of SC</li></ul><p></p><p><b><br>
Preferred Requirements</b></p><p></p><p><b><br>
Preferred Education</b>
</p><ul><li>BSN, MSW</li></ul><p><b>
Preferred Experience</b>
</p><ul><li>3-5 years</li></ul><p><b>
Preferred License/Registration/Certifications
</b></p><ul><li>RN, LMSW</li></ul><p></p><p><b><br>
Core Job Responsibilities</b></p><br>
<p></p><ul><li>
Complies with established policies and procedures</li><li>
Complies with regulatory requirements of utilization review and discharge planning</li><li>
Responsible for assessment and reassessment of patients&rsquo; physical, social, emotional and financial needs.</li><li>
Develops a comprehensive patient centered discharge plan, incorporating the patient goal into the discharge plan</li><li>
Communicates with the patient/family/care giver and interdisciplinary patient care team to facilitate patient care, development of a comprehensive patient centered discharge plan and utilization review functions</li><li>
Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care</li><li>
Documents clearly and concisely all contacts and information of the patient&rsquo;s case management</li></ul><p>
process in the medical record</p><ul><li>
Responsible for the core functions of the Utilization Management Plan</li><li>
Performs initial and subsequent utilization reviews utilizing criteria.</li><li>
With utilization review, obtains certification on admissions and continued certification by providing clinical information to the payer or to review companies designated by the patient&rsquo;s payer. Monitor and secures final certification up to and after patient discharge until resolved. Assists with management of incoming faxed communications</li><li>
With utilization review, assists with initial denial, peer to peer information, status determination and/or appeal process and communicates necessary information to the physician advisor, CM manager, denials team manager and/or QIO as required</li><li>
Uses communication tools to ensure that information is collected, reviewed, escalated if needed and disseminated appropriately for all commercial, managed care and government plans.</li><li>
Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate</li><li>
Performs timely data entry of information when results are received including covered, denied and avoidable days.</li><li>
Complies with delivery of regulatory notices - Important Message, Medicare Outpatient Observation Notice, Detailed Notice of Discharge and Hospital Issued Notices of Non-Coverage.</li><li>
Plans effectively in order to meet patient needs, manage length of stay and promote efficient utilization of resources.</li><li>
Provides cost-effective services through resource management and facilitating throughput while maintaining quality care and meeting customer service needs by collaborating with healthcare providers to coordinate care delivery</li><li>
Provides patient/family/caregiver with quality data-based information on post-acute providers to facilitate referrals to meet the care transition needs of the patient</li><li>
Utilizes a secure electronic platform to communicate with post-acute providers and payers</li><li>
Completes required education and ongoing competencies as assigned</li><li>
Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations</li><li>
Other duties as assigned</li></ul></div>

Case Manager

Physicians Data Trust

<div><p><b>Primary Purpose:</b></p><p>
Data input of referral authorization requests received from the Organization's Contracted Providers; generate member notifications as directed.</p><p><b>
Principal Duties and Responsibilities (* = essential functions):</b></p><ul><li>
Verifies eligibility and benefits for each referral. *</li><li>
Performs data entry of referral authorization requests for primary care visits, specialty consults, diagnostic/outpatient procedures, and admissions approved by the Medical Director. *</li><li>
Tracks and monitors progress of referral requests, responding to requests for additional information to assist the medical director's staff in making a decision. *</li><li>
Primary telephone call process for incoming calls into the Utilization Management Department. *</li><li>
Provides referral and authorization notifications to providers as directed. *</li><li>
Organizes and maintains electronic and hard copy filing systems for authorizations/referrals as directed.</li><li>
Prepares assigned correspondence and reports and complies with statistical data as directed.</li><li>
Tracks all types of references on the computer system on a hard copy log and compiles statistics monthly.</li><li>
Supports and facilitates teamwork within the department/group and the organization.</li><li>
Obtains CPT procedure codes and ICD-10 diagnosis codes from referring providers to assist with the determination of approval/denial.</li><li>
Ensures that network providers are utilized.</li><li>
Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization requests.</li><li>
Review file for completeness of required documentation, including but not limited to confirmation of receipt of notification copies of written notification correspondence with members and providers.</li><li>
Monitors and facilitates requisition requests for home health DME and other services in accordance with benefit guidelines.</li><li>
Coordinates all out-of-network outpatient specialist referrals with the Medical Director.</li><li>
Generates all required letters and notifications to patients and providers regarding referral authorizations, medical approval, and medical denial within established timeframes in accordance with policies, procedures, and contractual requirements.</li><li>
Provide the requested information during the appeals process.</li><li>
To organize and act promptly on pending denial files/cases to maintain designated turnaround times and physician communication.</li><li>
To provide information to licensed nursing staff regarding referrals that are 'not a covered benefit' and facilitate denial letters.</li><li>
To organize, manage, and prioritize workload effectively to process authorization request forms within the established time frame. *</li><li>
To refer appropriate authorization request forms to the IPA case manager based on established criteria.</li><li>
To educate and inform physicians and their office staff of any changes to the referral process, network changes, or other information about the referral process.</li><li>
Assist other departments in creating denial documentation during the appeals process.</li><li>
Document denial and denial rationale in data management systems. *</li><li>
Maintains/updates all required reporting for referrals/authorizations.</li><li>
Complete other duties and special projects as assigned.</li><li>
Ensure all required work is completed on time by the end of each shift.</li><li>
Participates in scheduled departmental/group meetings.</li><li>
Represents the department/group and organization professionally and positively.</li><li>
To perform other duties as assigned.</li></ul><p>
Job Specifications (KSAs):</p><ul><li>
Six months of experience in the medical field, either in a hospital, clinical, or insurance setting, that includes experience with computers.</li><li>
The ability to read, write, and speak English and perform other basic educational skills, as is generally obtained by completing High school or a GED equivalent.</li><li>
Bilingual English/Spanish preferred.</li><li>
Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred.</li><li>
Working knowledge &amp; expertise of ICD-10 &amp; CPT-4 codes.</li><li>
Demonstrated computer literacy. Excel experience helpful.</li><li>
Excellent communication skills in both oral and written modes, as well as superior telephone etiquette.</li><li>
Excellent Customer Service experience and proficiency required.</li></ul><p>
Pay Range $18 - $27.00 hourly DOE.</p></div><p></p>

Clinical Services UM Coordinator

Sharp HealthCare

<div>[Other; H.S. Diploma or Equivalent<p><b>
Hours</b><b>:</b></p><p></p><p><b>
Shift Start Time:</b></p>
8:30 AM<p><b>
Shift End Time:</b></p>
5 PM<p></p><p><b>
AWS Hours Requirement:</b></p>
8/40 - 8 Hour Shift<p></p><p><b>
Additional Shift Information:</b></p><p></p><p><b>
Weekend Requirements:</b></p>
As Needed<p></p><p><b>
On-Call Required:</b></p>
No<p></p><p><b>
Hourly Pay Range (Minimum - Midpoint - Maximum):</b></p>
$28.170 - $35.210 - $39.430<p></p><p><br>
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant&rsquo;s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.</p><p></p><b><br>
What You Will Do</b><br>
This position supports the system centralized utilization management department to meet division and organizational objectives, facilitate effective communication between department staff and the internal and external customers to the department, including but not limited to the business office, revenue cycle, physicians and payers. This position is accountable to ensure timely follow up on payer requests for clinical documentation, optimal inbound and outbound fax management to mitigate denials and ensure established timeliness response metrics are met, and reconciliation of hospital authorizations. Identification and escalation of concerns to the ICM System Centralized Utilization Management team to mitigate denials. Assists in capturing administrative days under the direction of the UM CM's. A key member of the UM customer service team to meet and exceed the customer's expectations.
<br>
<br>
<b>Required Qualifications</b><ul><li>
H.S. Diploma or Equivalent
</li></ul><br>
<b>Preferred Qualifications</b><ul><li>
Other Health related education.
</li><li>Other Successful completion of Medical Assistant Program or equivalent.
</li><li>2 Years hospital experience.
</li><li>2 Years Medi-Cal experience.
</li></ul><br>
<b>Essential Functions</b><br>
<ul>
<li>Monitor Utilization Management Queues
<br>
<br>
Works with the other members of the UM team to monitor timely management of the UM queues. Escalates to management when queues are outside of established turnaround timeframes.
<br>
Verifies current insurance plan eligibility. Assists the UM CM&rsquo;s to report inaccurate insurance information on the facesheet.
<br>
Reviews patient list and prioritizes/plans for the day.<br>
Contributes to the continuous improvement initiatives of the system centralized utilization management team to deliver quality interventions in a timely manner.<br>
Maintains proactive communications with insurance representatives, UM CM&rsquo;s and TP CM teams at the site level.<br>
Maintains a current payer contact list to support utilization management activities.
<br>
Maintains passwords and access to payer portals to ensure timely UM authorization capture.</li>
<li>Teamwork and Collaboration
<br>
Acts as facilitator between payors and UM team members.<br>
Ensures UM team members are updated daily and thought out the day as needed.<br>
Keeps the ICM UM Leadership aware of inability to complete assigned duties or tasks.
<br>
Responsible for timely and accurate retrieval and appropriate action on departmental phone messages and necessary fax<br>
communication.<br>
Work closely with revenue cycle to ensure the latest reimbursement and contract information is available to the utilization managers.<br>
Work closely with the revenue cycle to make sure all are aware of denials real time.<br>
Supports staff and leadership to meet department objectives.</li>
<li>Database Management<br>
Assists with the processing of letters of authorization, appeal or denial.<br>
Prepare databases and written reports for leads, manager, and director in a timely manner as requested and within the scope of work.<br>
Initiates and participates in the creation and development of forms and lists.<br>
Assist UM case managers and physician advisors with denial cases, setting up peer to peer reviews as needed.<br>
Must demonstrate attention to detail and accuracy.</li>
<li>Department Operations<br>
Ensures UM staff have appropriate resources and information to expedite smooth transition to through continuum
<br>
and optimize third party payer reimbursement.<br>
Monitor authorization for all patients in-house to ensure reimbursement and payment for correct level of care.<br>
Monitor completion of retro reviews and notifies lead of reviews pending by noon the second business day of the request.<br>
Provide needed documentation for Medi-Cal TAR free process, and complete TARs timely for those patients who are not<br>
appropriate for the TAR free process.<br>
Attends department meetings.<br>
Initiates and participates in huddles and quality improvement activities.<br>
All work is consistently completed on time and in a timely manner.</li>
<li>Authorization Reconciliation
<br>
Confirm discharges from previous day and ensure that authorizations or denials are captured and documented.<br>
Documents activities as per the departmental processes and with the electronic medical record.</li>
<li>Industry Skills and Competency<br>
Obtain detailed benefit coverage for complex requests specific to patient plan coverage.<br>
Investigate and follow-up on all eligibility issues in accordance with hospital guidelines.<br>
Performs review of all prior authorizations, entering into the electronic medical record.<br>
Researches and assists in the denial process-gathers documentation for the UR lead, director, and attending physician.</li>
<li>SCMG UMRC Specific<br>
Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage.
<br>
Apply the principles of SCMG guidelines and Health Plan benefit guidelines to approve referrals designated at the CRC level.
<br>
Investigate and follow-up on all eligibility issues in accordance with health plan and SCMG guidelines.
<br>
Process referrals for prior authorization.
<br>
Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, inpatient admission, durable medical equipment, home care and other miscellaneous services for the efficient and effective delivery of inpatient services.<br>
Performs review of all prior authorization referrals. (Responsible for all levels of the referral from generation, approval and acquisition).<br>
Obtains necessary medical information for use by themselves, Medical Directors, the Hospitalist Physician and/or Case Manager.<br>
Identifies and refer requests for review by higher level staff (Medical Director, Hospitalist or HCM) within department turn around time (TAT) standards.<br>
Research and assist in the denial process - gathers documentation after review by medical director, ensure packet information is complete, assesses and select the appropriate denial reason. Maintain mandated TAT for denials.<br>
Obtains and gathers clinical information from multiple sources including use of Sharp and/or Hospital applications to retrieve patient medical records for review by Hospitalist Case Managers, SNF's or outpatient service providers.<br>
Verifies and documents eligibility and benefit details.<br>
Obtains prior authorizations for specific medications, through SCMG Pharmacy or through the patient's health plan when applicable. Has all information available to help with the review process.<br>
Informs and distributes health plan criteria to the Medical Director, CM or themselves to make a determination regarding an authorization for service or equipment.<br>
Updates inpatient IDX referrals with correct diagnoses, bed type and disposition.<br>
Generates or assist in the dissemination of Case Management Referrals.<br>
Generate informational referrals for patients that are accepted to hospice while admitted as inpatient.<br>
Research and interpret all ICD-10, CPT and HCPC coding using appropriate tools.<br>
Make determination on the more complex claims that are designated CC authorization level within SCMG TAT guidelines.<br>
Coordinates, reviews and processes more complex retrospective claims for medical care and services, including, SNF inpatient admission, medical transportation, durable medical equipment and other miscellaneous services for the efficient and effective facilitation of claim adjudication.<br>
Tracks and informs identified personnel of expired patients.</li>
<li>Professional Development<br>
Actively identifies gaps in skills and competencies and participated in seminars/classes to enhance gaps.<br>
Attends and actively participates in department/team process/quality improvement activities.<br>
Actively participates in all-staff meetings and stand-ups.</li>
</ul>
<br>
<b>Knowledge, Skills, and Abilities</b><ul><li>
Bilingual preferred.</li>
<li>Knowledge of hospital payors preferred.</li>
<li>General filing knowledge.</li>
<li>Demonstrated proficiency in Microsoft Word, Microsoft Excel, Microsoft Outlook, and other software programs.Excellent organization, managerial and time management skills with the ability to multi-task.</li>
<li>Excellent analytical, problem solving and supervisory skills, knowledgeable of medical terminology, and current standards of clinical practice, professional counseling, mentorship and resource allocation.</li>
<li>Knowledgeable in the use of ICD-10, CPT4, and HCPC coding systems.</li>
<li>Proficient in typing and computer data entry (45 wpm).</li>
<li>Excellent verbal and written communication skills.</li>
<li>Ability to read, speak, and hear English clearly.</li>
<li>Able to work independently in research and decision making with minimal direction from higher level of staff.</li></ul><p><br>
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class</p></div>

Utilization Management Resource Coordinator - Sharp Spectrum Corporate Offices - Full-Time - Day Shift

Blue Cross and Blue Shield of North Carolina

<div></div><div>We're seeking a Senior Episodic Care Manager to join our Behavioral Health Team! The Senior Episodic Care Manager - Behavioral Health Autism Services utilizes advanced knowledge and experience in utilization management and medical reviews to perform varied senior-level functions for the department. Drives operational efficiencies, works with internal and external partners for care coordination, and provides input to valuable Utilization Management (UM) initiatives that support the delivery of high quality and cost-effective care across the health care system.<div></div><div>
What You'll Do</div><ul><li><div>
Support member care coordination and departmental goals by performing Perform clinical evaluation and review of various member services for prior authorization or transition of care needs as needed to meet departmental goals</div></li><li><div>
Act as a subject matter expert to support clinical UM staff as first point of contact with process, business, and/or clinical questions.</div></li><li><div>
Serve as point of contact for internal stakeholders to provide expertise on utilization management related to discharge planning, the review of sales documents and benefit booklets, and/or other project/initiative support.</div></li><li><div>
Apply significant expertise in discharge planning and utilization management to expedite the coordination of services and equipment and facilitate safe and effective discharge plans for our members.</div></li><li><div>
Provide precepting support and mentorship to new hires and/or those needing refresher assistance.</div></li><li><div>
Serve as co-trainer for in-services</div></li><li><div>
Create and maintain relevant desktop procedures or process documentation.</div></li><li><div>
Provide system and project testing support as needed.</div></li><li><div>
Support team effectiveness through management of UM queues and work assignments.</div></li><li><div>
May provide coverage for representation on projects in place of leadership as needed due to other priorities.</div></li></ul><div></div><div>
What You Bring</div><ul><li><div>
BCBA with at least 3 years experience in clinical work</div></li><li><div>
Additional direct experience in utilization management, with demonstrated success in the ECM role, meeting or exceeding metrics and quality goals.</div></li><li><div>
Proven expertise in UM functions, and processes and/or discharge planning.</div></li><li><div>
Must have a valid BCBA license within the US and have started application for NC license.</div></li></ul><div></div><div>
What You&rsquo;ll Get</div><div>
The opportunity to work at the cutting edge of health care delivery with a team that&rsquo;s deeply invested in the community</div><ul><li><div>
Work-life balance, flexibility, and the autonomy to do great work</div></li><li><div>
Medical, dental, and vision coverage along with numerous health and wellness programs</div></li><li><div>
Parental leave and support plus adoption and surrogacy assistance</div></li><li><div>
Career development programs and tuition reimbursement for continued education</div></li><li><div>
401k match including an annual company contribution</div></li></ul><div></div><div>
Salary Range</div><div>
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.</div><div></div><ul><li><i>Based on annual corporate goal achievement and individual performance.</i></li></ul><br>
$81,068.00 - $129,708.00<div></div><div>
Skills</div>
Clinical Decision Support (CDS), Clinical Evaluations, Clinical Experience, Clinical Support, Medical Review, Medication Management, Patient Advocacy, Patient Care Coordination, Patient Discharge Planning, Patient Education<div>
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JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on <div>https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC</div>. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: <div>HR.Staffing@BCBSNC.com</div>.</div></div>

Senior Episodic Care Manager - Behavioral Health Autism Services

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