UM Case Manager

2 weeks ago

Whittier, California, United States Innovative Management Systems Incorporated Full time
Job Summary

We are seeking a highly skilled and experienced UM Case Manager to join our team at Innovative Management Systems Incorporated. As a key member of our Utilization Management team, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.

Key Responsibilities
  • Comply with UM policies and procedures, annual review of UM policies, and may take part in policy and procedure creation
  • Follows in-patient and out-patient cases
  • Review and screen incoming service referral requests for medical appropriateness using medical necessity and benefits criteria for the various product lines, daily production, standard of minimum 50-75 referrals/day with accuracy and quality; and present appropriate cases to Medical Director for potential denial determinations while adhering to regulatory timeframe standards.
  • Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria; presents cases to Medical Director for potential denial determinations
  • Troubleshoots authorization/referral calls, emails, and urgent faxes within CMS guidelines
  • Utilize clinical skills to coordinate, document and communicate all aspects of the precertification and utilization/benefit management program.
  • 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.
  • Gathers clinical information and the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for precertification process.
  • Act as clinical resources to referral staff and make appropriate referrals.
  • Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
  • Communicates with health plans/providers/members and other parties to facilitate member care/treatment and to assist in making decisions for the precertification process.
  • 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.
  • Identify and suggest process and system improvements that improve the goal of providing a positive, exclusive member marketing experience.
Requirements
  • Active and Valid RN License or LVN License in California.
  • 2 years health plan, IPA or MSO experience in management.
  • Experience with clinical issues, clinical guidelines, case management and managed care.
  • In-patient and Out-patient experience.
  • Working knowledge of IC, DHS, DMHC, NCQA, and CMS Standards.
Preferred Skills
  • Strong analytical and critical reasoning, communication, and customer service skills
  • Good presentation, verbal and written communication skills, and ability to collaborate with co-workers, senior leadership and other management, as well as members and business affiliates
  • Ability to prioritize and organize multi-faceted/multiple responsibilities, time manage and prioritize in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
  • Proficient with Microsoft applications, QuickCap, EZCAP, and crystal reports, preferred
  • Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
  • Detail-orientated and ability to work autonomously and in a team.
  • Ability to time manage and prioritize duties and responsibilities.
Compensation

Hourly Wage

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