Utilization Management Professional

Company Description

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.

Job Description

License and Educational requirement: LCSW, LCPC or RN. A Masters degree is required for ALL licenses EXCEPT for the RN. A Bachelors degree is required for the RNs.
Description:
Under general supervision by management, 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.

ESSENTIAL FUNCTIONS: - Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures. - Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms. - In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care. - Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria. - Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence. - 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. - Participates in network development including identification and recruitment of quality providers as needed. - Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner. - Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

Qualifications

Requirements/Certifications:
THIS IS A TEMP-TO-PERM POSITION.
The candidate will work an 8 hour shift that could start between the hours of 8am – 10:30am.
Caseload: 25-30 reviews per day. This position is 98% telephonic.
Additional Information: The candidate MUST have BH experience. There will be rounds with a Doctor for 15 mins everyday. Travel maybe required to a local hospital with a mileage rate of $0.54/mile. The manager is looking for 3 years of Inpatient Medical experience, 3 years of Utilization experience, Concurrent Review experience and HMO exp. Training will be 3 – 4 weeks long that will include Code of Conduct, Systems App and Shadowing. Credentialing Paperwork will be completed during training.

Additional Information

Riya Khem

Life Science Recruiter 

Integrated Resources, Inc.

IT Life Sciences Allied Healthcare CRO

Certified MBE |GSA - Schedule 66 I GSA - Schedule 621I

DIRECT # - 732 -844-8721 | (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549