SIHO Insurance Services
  • - Medical Management
  • Columbus, IN, USA
  • Salary
  • Full Time
  • full benefit package

 

Job Summary:

This is an exempt position reporting to the Director of Medical Management Department. The position is responsible for the receiving and rendering of decisions on prior and retro authorizations and utilization review using clinical guidelines. This is to be accomplished in the most cost-effective manner without compromising quality of care in order to promote optimal outcomes for all parties involved. 

 

Key Responsibilities:

  • Receipt of PA via various means including phone, fax, email and web portal
  • Performs concurrent and retrospective reviews on all inpatient, facility requests. Monitors level and quality of care. These reviews will be completed utilizing the Milliman Care guidelines.
  • Coordinating with Nurse Case Manager in proactively  managing acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
  • Responsible for the review and completion of other appropriate request that require prior authorization such as the request for purchase of durable medical equipment, specialty medications, testing such as MRI's, CT scan utilizing the Milliman Care guidelines as well as the Medical Management guidelines.
  • Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds.
  • Monitors all utilization reports to assure compliance with reporting and turnaround times.
  • Addresses care issues with Director of Care Management and Chief Medical Officer/Medical Director as appropriate.
  • Identify potentially high dollar claiments. Refer to Nurse Case Manager as appropriate. Notify reinsurance carrier(s) as appropriate. Consults with and notifies physicians, health care providers and outside agencies regarding authorization decisions.
  • Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
  • Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
  • Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refers members for Case Management accordingly.
  • Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities.
  • Prepares notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation.
  • Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Program Manager.
  • Provides backup for Case Manager.
  • Work as an interdisciplinary team member within Medical Management and others in all SIHO departments.
  • Provide back up for other members of the Medical Management team when needed.
  • Other duties as assigned.
  • Completes 10 hours of continuing education annually
  • Complies with all CHS/SIHO policies and procedures and URAC accreditation standards.

 

 

 

Minimum Skills and Educational Requirement:

  • RN or LPN with minimum of  5 years clinical experience
  • Current, unrestricted RN or LPN  license
  • Sound clinical background
  • Analytical skills
  • Verbal and written communication skills
  • Knowledge of community resources
  • Sound understanding of changing healthcare systems and reimbursement models
  • Basic computer skills-Excel, Word
  • Ability to communicate with physicians and office staff

 

Other:   

*         Confirmation of excellent attendance record

*         General knowledge and understanding of an office environment

*         Represent CHS by participating (volunteering) in community activities

 

SIHO Insurance Services
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