Health Services - Spec, Utilization

Ampcus Inc.•Baltimore, MD

1d•Remote

About The Position

Ampcus Inc. is seeking a highly motivated Utilization Review Specialist to join their team. This is a 3-month, 100% remote position with flexible hours. The role involves performing utilization management reviews using clinical expertise and critical thinking to analyze clinical information, contracts, and guidelines to determine the appropriateness and authorization of medical and behavioral health services.

Requirements

Minimum 5 years of clinical nursing experience
Background in critical care or managed care
Prior knowledge of managed care and utilization review
Proficiency with MCG guidelines
Active compact RN license or Maryland RN license
Strong knowledge of Microsoft applications
Experience with both Facets and Guiding Care (mandatory)
Bachelor's Degree in Nursing
2 years Care Management experience
Effective written and interpersonal communication skills
Strong assessment skills with the ability to make rapid connection with Member telephonically
Ability to work effectively with large amounts of confidential member data and PHI
Ability to prioritize workload during heavy workload periods
Ability to multitask, prioritize, and maintain a dynamic personal organization system that allows for flexibility
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint
Excellent analytical and problem-solving skills
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire

Nice To Haves

LPN license is acceptable
In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
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.
LPN - Licensed Practical Nurse - State Licensure
CNS-Clinical Nurse Specialist
Clinical UM expertise, regulatory compliance knowledge, experience in Guiding care platform.

Responsibilities

Perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage.
Analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements.
Determine medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
Follow NCQA Standards, Medical Policy, all guidelines, and departmental SOPs to manage member assignments.
Understand all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
Conduct 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.
Collaborate with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
Apply sound clinical knowledge and judgment throughout the review process.
Coordinate non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities.
Follow member contracts to assist with benefit determination.
Make appropriate referrals and contacts as appropriate.
Offer assistance to members and providers for alternative settings for care.
Research and present educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.