Summary of Responsibilities:
Provides concurrent and retrospective utilization reviews, large case management and other programs to improve the quality of medical care and control costs. Works with minimal supervision and is responsible to make an established range of decisions, escalating to director when necessary and updates manager on a regular basis.
Uses documented criteria for both inpatient and outpatient medical care to promote quality medical care at reasonable cost.
Performs prospective and concurrent utilization reviews to determine medical necessity for inpatient admission, inpatient continued stay and selected outpatient services and for most efficient utilization of third-party services.
Documents individual cases for the purposes of cost savings and efficiency analyses and legal record.
Monitors potential high-cost claims for early intervention with case management.
Keeps Benefits Management and Company Physicians informed on an ongoing basis of the status of all large case management cases. On all other areas, review with Benefits Management or the Medical Department on a case-by-case basis.
Communicates with physicians, office staff, hospital utilization personnel, medical records, social services and members (associates) as necessary.
Acts as a source of medical information for Benefits Department.
Attends seminars and review journals and professional publications to keep up-to-date on current medical trends.
Conducts and coordinates case management activities for workers compensation and non-occupational
Short-Term Disability, Return-To-Work and Family Medical Leave Act cases.
Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality and protection of personal information, including, but not limited to, personal health information and personally identifiable information.
Performs other duties as assigned by management.
Proven working knowledge of utilization management principles as applied to third-party review systems, including effective use of physician consultants, structure and operation of preadmission review, concurrent review, discharge planning, second opinion, catastrophic case management programs, ACD telephone systems and data collection, analysis and reporting.
Demonstrated familiarity with the major criteria sets and length of stay guidelines currently used by most systems.
Proven working knowledge of International Classification of Diseases - 10 codes (ICD-10).
Demonstrated familiarity with ICD10-CM and CPT-4 coding and DRG-based systems.
Proven strong knowledge of medical technology, healthcare resources and contemporary trends in the healthcare delivery system.
Demonstrated experience handling multiple duties and completing assigned tasks accurately and on a timely basis. Must cite examples of proven ability to work independently to schedule and initiate reviews and works with patients, providers and claim processors.
Proven excellent verbal and written communication skills with the ability to successfully interpret and communicate with all levels of administration, healthcare providers and members in a clear, focused and concise manner. Expected to provide examples of written work such as correspondence, reports, etc.
Demonstrated ability to use complete discretion in handling confidential and sensitive materials.
Works in an office setting and remains continuously in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.
Frequently moves around the office to access file cabinets, office machinery, etc. While accessing file cabinets, frequently uses upper extremities to reach by extending hands and/or arms in any direction.
Computer Skills and Knowledge of Hardware & Software Required:
Certifications & Licenses (i.e., Series 6 & 63, CPA, etc.):
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