Health Services - Spec, Utilization Management

Ampcus Inc.•Baltimore, MD

1d•Remote

About The Position

Ampcus Inc. is seeking a highly motivated Utilization Management Specialist to join their team. This is a temporary position with the potential to become permanent, offering a 100% remote work environment. The specialist will utilize key principles of utilization management to perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Leveraging clinical expertise and critical thinking skills, the specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements to contribute to the determination of appropriateness and authorization of clinical services for both medical and behavioral health.

Requirements

UM experience
RN/LPN state licensing or compact
Experience with Medicare Medicaid [Government Medicaid/Medicare Dsnap]
Medicare and Medicaid background
Proficient with technology like computer, windows, able to work independently
Clinical experience – 5 years
Nursing experience – Emergency background or critical care – nice to have
2 years UM/care management – required
MCG required
GuidingCare – is must have
RN/LPN with compact license for MD
Manage 30-35 cases a day
Bachelor's Degree in Nursing
5 years Clinical nursing experience
2 years Care Management
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues
Proficient Must have strong assessment skills with the ability to make rapid connection with Member telephonically
Proficient Must be able to work effectively with large amounts of confidential member data and PHI
Expert Must be able to prioritize workload during heavy workload periods
Proficient Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility
Advanced Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint
Proficient Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required or LPN - Licensed Practical Nurse - State Licensure

Nice To Haves

Emergency background or critical care nursing experience
Facets knowledge
CNS-Clinical Nurse Specialist
Working knowledge of managed care and health delivery systems.
Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards.
Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment, and the ability to confidently use the internet as a resource.

Responsibilities

Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
Follows NCQA Standards, Medical Policy, all guidelines, and departmental SOPS to manage member assignments.
Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
Conducts research and analysis of pertinent diseases, treatments, and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
Collaborates with medical directors, sales and marketing, contracting, provider, and member services to determine appropriate benefit application.
Applies sound clinical knowledge and judgment throughout the review process.
Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities.
Follows member contracts to assist with benefit determination.
Makes appropriate referrals and contacts as appropriate.
Offers assistance to members and providers for alternative settings for care.
Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.