Outpatient UM Clinician

Summary

Reporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities

• Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required
• Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
  • Promote improved quality of care and/or life
  • Prevent hospitalization when possible and appropriate
  • Provide for continuity of care
  • Ensure appropriate levels of care are received by members
• Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business
• Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers
• Identify complex authorization requests and appropriately refer to Case Management personnel
• Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests
• Work effectively with all other sub team members within Outpatient UM
• Maintain prompt and open communication with the Denial team to meet tight turnaround time (usually with 24hours of initial request)
• Communicate with Health Plan Liaisons in the event that a precertification requests requires health plan review, ensuring review is completed in compliance with timeliness standards
• Outreach to Provider Network Operations team to address provider related referral insufficiencies
• Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources
• Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.
• Maintain knowledge of UM policy and procedures
• Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians

Minimum Job Requirements:

• Current California RN or LVN license
• 2+ years of experience in utilization management preferred
• Proficiency with Microsoft Office Programs; primarily Word and Excel
• EZ-CAP® knowledge a plus

Skills and Abilities:

• Excellent relationship management skills with the ability to communicate effectively with all stakeholders
• Strong organizational, task prioritization, and delegation skills
• Ability to collaborate successfully with all levels of the organization