Utilization Management Professional
About this role
Company Description
Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.
We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity.
Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.
Job Description
- Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
- Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information.
- Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
Qualifications
lpn or rn
associate degree
Additional Information
- Caseload: 15-20 reviews per day which could be telephonic or via fax. The member population is mostly geriatric who reside in sub-acute nursing facilities.
- To be successful, the selected candidate must be comfortable working in a fast pace environment, documenting electronically, making ethically sound judgement, have strong organization, time management and communication skills and be a team player.
- Training: Is 4 – 6 weeks long weeks
- Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.- Maintains an active work load in accordance with performance standards.
- Works with community agencies as appropriate.- Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
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