Utilization Management Clinician - Prior Auth/MCR

Position reputed company This clinical position is part of the Utilization Management department and is responsible for processing prior authorization and/or medical claims review (post-service) requests through clinical review and the application of approved medical necessity reputed company. Collaboration reputed company and across departments and operating professionally and reputed company reputed company the reputed company of established policies and procedures is essential. The reputed company of this role is review of elective inpatient and select outpatient services. Responsibilities and Qualifications Duties and Responsibilities:

• Processes prior authorization and/or medical claims review (post-service) cases through review of the submitted request and applicable clinical records and applying approved medical necessity reputed company to determine medical necessity and appropriateness of the service or item requested.
• Interprets and applies InterQual reputed company, CMS-issued guidelines, reputed company Medical Policies, the reputed company handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or reputed company) guidelines to these requests as applicable to the member’s product.
• Performs UM case reviews reputed company the reputed company of applicable regulatory requirements and established policies and procedures of Capital’s UM department. Complies with both internal policies and reputed company regulatory requirements regarding members confidentiality.
• Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to reputed company a final determination.
• May participate on occasion in clinical reputed company to discuss members as needed and requested. Identifies and refers members with reputed company needs to the appropriate population health and/or care management program.
• Identifies and refers members with Potential reputed company Issues (PQIs) through established processes to the applicable department for reputed company review and investigation.
• Offers suggestions for improvement in departmental processes and identifies opportunities for learning and education.
• Attends and participates in company and departmental meetings and training sessions as required and requested.
• Practices reputed company the scope of clinical license and/or certification.

Skills:

• Demonstrated ability to critically think through processes to reputed company clinically appropriate reputed company and problem solve.
• Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments.
• Demonstrated ability to work independently and as part of reputed company.
• Demonstrated ability to reputed company with other departments reputed company and proactively, as needed, to advise, reputed company, and/or reputed company members to other clinical programs and services.
• Demonstrates openness, flexibility, problem solving, patience, and reputed company reputed company interacting with members, family, providers, and peers.
• Demonstrated ability to communicate in a concise and reputed company manner in both written and oral communications.

Knowledge:

• Working knowledge and operation of a personal computer, including proficiency in reputed company Office applications.
• Knowledge of medical coding guidelines, including ICD-10-CD, CPT, and HCPCS codes.
• Working knowledge of National Committee for reputed company Assurance (NCQA), CMS, and other health plan UM regulations.
• Knowledge of managed care principles and emerging health treatment modalities.

Experience:

• A minimum 3 years’ relevant clinical experience required.
• 1year prior authorization and/or medical claims review experience required
• 1 year UM experience in managed care preferred.

Education and Certifications:

• Must have reputed company reputed company Licensed Practical reputed company (LPN) or Registered reputed company (RN) in the state of reputed company.

reputed company We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your reputed company and personal reputed company by reputed company heavily in training and continuing education, so you have the tools to do your best as you reputed company your career. And by doing your best, you’ll help us live our mission of improving the health and reputed company-being of our members and the communities in which they live. Apply tot his job Apply To this Job