This position will be responsible for conducting utilization review/medical management for all services including training/mentoring other team members and performing preliminary research on requested topics. In addition, the incumbent may provide technical assistance, medical record review and support to provider staff and physician reviewers.
Essential Functions
Performs prospective, concurrent or retrospective utilization review/medical management for all services including appropriateness of quality of care based on contract, state, or URAC requirements.
Screens individual situations according to specific criteria to determine if care is appropriate.
Refers cases that fail to meet screening criteria to peer reviewer.
Coordinates and participates in peer-to-peer review as warranted.
With prior management approval, may deviate from criteria with proper justification to authorize the service.
Serves as liaison between peer reviewer, provider, facility and/or subscriber.
Coordinates and participates in appeal process as directed by management.
Trains or serves as a mentor to team members and physician reviewers to ensure reviews and appeals are conducted thoroughly and within specified time frames.
Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
Assists in compliance reporting.
Performs miscellaneous duties as assigned.
Requirements
Two- or three-year degree in nursing .
3 – 5 years recent experience working in a clinical or behavioral health environment
This contract requires a valid California Nursing License or the ability to obtain this licensure.
Because of the nature and immediacy of the work, the ability to maintain regular and predictable attendance is essential.
Knowledge of URAC standards preferred.
Strong understanding of mental health diagnoses, substance abuse treatment, and utilization management criteria (e.g., InterQual, MCG).
Proficiency with Electronic Health Records (EHR) and utilization management software.
Skills:
Positions working on specific contracts may require U.S. Citizenship.
