Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Utilizes clinical skills to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination ofdischarge planning needs. Obtains the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. Evaluates the options and services required to meet the member's health needs, in support and collaboration with disease management interventions. Performs prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests.
Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekend and/or holidays as required by State and Federal regulations in order to maintain operational compliance.
This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a Central Health office in Austin, Texas. Remote work not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Provides concurrent review and prior authorizations (as needed) according to policy.
Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.
Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and cost.
Completes assigned work plan objectives and projects on a timely basis.
Collect pertinent documentation and conduct medical services review applying appropriate national standardized medical criteria, Sendero medical policy, and state and federal guidelines.
Perform discharge planning activities in coordination with facility or provider case manager.
Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan.
Consult with a Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval.
Maintain open communication flow with to other care management staff to facilitate smooth transition and
follow‑up as member is transitioned from one level of care and/or service to another.
Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities.
Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures.
Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner.
Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management.
Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines.
Work independently and handle multiple projects simultaneously.
In depth knowledge of InterQual and other references for length of stay and medical necessity determinations.
Computer Literate (Microsoft Office Products).
Computer Literate (Microsoft Office Products).
Ability to abide by Sendero’s policies.
Ability to maintain attendance to support required quality and quantity of work.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
High School Diploma or equivalent Required and Completion of an accredited (RN) or an accredited (LVN) program Required
One (1) year clinical practice experience Required AND Two (2) years managed care experience with utilization management and/or case management
Active, unrestricted State Registered Nursing license in good standing
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