Job Description

Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Mentors and trains new team members. Assesses services for members to ensure optimum outcomes, cost effectiveness and
compliance with all state and federal regulations and guidelines. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. This position also trains and mentors new team members as well as assesses services for Sendero members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Utilizes clinical skills to review and monitor members' utilization of health care services with the goal
of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination of discharge planning needs. Obtains the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. Evaluates the options and services required to meet the member's health needs, in support
and collaboration with disease management interventions. Performs prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests.

Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekend and/or holidays as required by State and Federal regulations in order to maintain operational compliance.

• Provides concurrent review and prior authorizations (as needed) according to policy.
• Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and cost.
• Collect pertinent documentation and conduct medical services review applying appropriate national standardized medical criteria, Sendero medical policy, and state and federal guidelines.
• Perform discharge planning activities in coordination with facility or provider case manager.
• Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan.
• Consult with a Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval.
• Maintain open communication flow with to other care management staff to facilitate smooth transition and follow-up as member is transitioned from one level of care and/or service to another.
• Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities.
• Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures.
• Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner.

Knowledge, Skills and Abilities:

• Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management.
• Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines.
• Demonstrated ability to lead, communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In depth knowledge of InterQual and other references for length of stay and medical necessity determinations.
• Subject matter expert with NCQA requirements.
• Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products).
• Computer Literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• Ability to abide by Sendero’s policies.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

EDUCATION:

• High School Diploma or equivalent r equired.
• Completion of an accredited (RN) -OR- an accredited (LVN) program r equired.
• Bachelor's Degree in nursing or health related field p referred.

EXPERIENCE:

• 1 year clinical practice experience r equired.
• 2 years managed care experience with utilization management and/or case management r equired.

REQUIRED CERTIFICATIONS/LICENSURE:

• Active, unrestricted Texas State Registered Nursing license or Texas Licensed Vocational Nursing license in good standing required.
  • Must hold and maintain this certification(s) as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work.
• Case Management Certification (CCM), Utilization Management Certification (CPHM) or other healthcare certification p referred.

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