Alhambra, CA, US
Contract to Hire
$25,000.00 - $30,000.00 /Year
To implement the effectiveness and best practices of Utilization Review, the nurse will provide high quality medical care review by appropriately applying the State, Federal, health plan and or clinical guidelines used to determine medical necessity. All reviews are based on established hierarchy of criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
* Comply with UM policies and procedures. Annual review of UM policies.
* Review & screen incoming service referral requests for medical necessity
* Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
* Knowledge of health plan DOFRs and contracts and how they apply to the review process.
* Review member' utilization and claim history when processing a referral.
* Apply VAE, Correct Coding Initiative as per P&P.
* Document overview of the members referral request prior to sending to the Medical Director for review
* Provide Medical Director with specific criteria for the referral based on the hierarchy.
* Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro services.
* Daily production standard is a minimum of 150-250 referrals/day with accuracy & quality
* Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria;
* Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meets criteria and can be authorized by UM staff
* Act as clinical resources to all departments within NMM.
* Screen for potential California Children Services (CCS) or ambulatory case management referrals.
* Communicates with health plans/providers/members and other parties to facilitate member care/treatment and to assist in making decisions for the precertification process.
* Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients.
* Review claim/referral appeals and unauthorized claims, forwarding them for medical director/UMC review and determination when appropriate.
* Work closely with Claims Manager on overlapping issues such as rates and procedures/CPT codes for new procedures.
* Identifies potential TPL/COB cases, investigates TPL/COB issues, and notifies the appropriate internal departments
* Attend to provider and interdepartmental calls in accordance with exceptional customer service
* Reports to Supervisor on activities or problems occurring throughout the day.
* Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Maintains strictest confidentiality at all times.
We know that a company's success starts with its employees. We also know that an individual's success starts with the right career opportunity. As a Best of Staffing® Client and Talent leader, Aerotek's people-focused approach yields competitive advantage for our clients and rewarding careers for our contract employees. Since 1983, Aerotek has grown to become a leader in recruiting and staffing services. With more than 250 non-franchised offices, Aerotek's 8,000 internal employees serve more than 300,000 contract employees and 18,000 clients every year. Aerotek is an Allegis Group company, the global leader in talent solutions. Learn more at Aerotek.com.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
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