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Healthcare Utilization Manager

2 months ago

Atlanta, Georgia, United States Sonder Health Plans Full time
Job Description:

The Clinical Review Specialist role at Sonder Health Plans is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance.

By continuously reviewing and auditing member treatment records, the Clinical Review Specialist will ensure members do not receive unnecessary procedures, ineffective treatment, or experience unnecessarily extensive hospital stays.

Key Responsibilities:
  • Concurrent review of members' clinical information for efficiency and effectiveness.
  • Ongoing review of preauthorization requests for medical necessity and appropriateness.
  • Coordinate member discharge planning needs as part of an integrated care team to ensure timely and smooth transitions.
  • Employ effective use of knowledge, critical thinking, and skills to:
  • Advocate quality care and enhanced quality of life for members.
  • Prevent member complications during hospital stays and advocate for decreased hospital stay when appropriate.
  • Actively participate in discharge planning processes, engaging assigned Case Manager for MLTC and SNP members as well as the members' care team to ensure timely discharge, appropriate follow-up, and continuity of care.
  • Facilitate requests for Sub-Acute care, DME, Home Health Care, and Transportation for members.
  • Refer cases with quality-of-care concerns to the Chief Medical Officer and Quality Department for further review and action.
Requirements:
  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
  • Ability to plan, implement, and evaluate individual member care programs to ensure optimal outcomes.
  • Knowledge of medical billing procedures and regulations.
  • Intermediate skills in Microsoft Office suite and Google applications.
  • Ability to manage a large workload and thrive in a results-driven, fast-paced environment.
  • Experience with Medicare Managed Care utilization management and applicable regulations.
  • Commitment to maintain working knowledge and compliance with departmental policies & procedures, CMS requirements, NCQA, AAHC, as well as Federal & State guidelines, as applicable.
  • Ability to practice ethics in daily operations, demonstrating professionalism and commitment to success, inspiring others towards high-level of engagement and teamwork.
  • State licensure as a Practical Nurse (LPN) in good standing.
  • Minimum 1-year prior experience completing utilization reviews for an HMO.
Working Conditions:
  • No or very limited physical effort required.
  • Work environment involves minimal exposure to physical risks, such as operating dangerous equipment or working with chemicals.
  • Sonder Health Plans utilizes a hybrid work model that is based upon position requirements, performance, productivity, and company needs and may be modified or changed at any time.

Sonder Health Plans is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.