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.
This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a Central Health office in Austin, Texas. Remote work not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without
accommodations):
Knowledge/Skills/Abilities:
MINIMUM EDUCATION: High School Diploma or equivalent Required and Completion of an accredited (RN) or an accredited (LVN) program Required
MINIMUM EXPERIENCE: One (1) year clinical practice experience Required AND Two (2) years managed care experience with utilization management and/or case management
REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these
certifications/licensure will result in suspension of work:
1. Active, unrestricted State Registered Nursing license in good standing
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