Health Services - Spec, Utilization Management

Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team.

Position: Utilization Management Specialist - 49937-1

Duration: 6 Months – Temp to perm.

Location: 100% Remote (Baltimore, MD)

Must Have Skills:

• UM experience
• RN/LPN state licensing or compact
• Experience with Medicare Medicaid [Government Medicaid/Medicare Dsnap]
• Medicare and Medicaid background
• Proficient with technology like computer, windows, able to work independently
• Clinical experience – 5 years
• Nursing experience – Emergency background or critical care – nice to have
• 2 years UM/care management – required
• MCG required
• GuidingCare – is must have
• Facets knowledge is good to have
• RN/LPN with compact license for MD
• Manage 30-35 cases a day
• DMV candidate can be considered - license for MD is required

Purpose:

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements to contribute to the determination of appropriateness and authorization of clinical services both medical and behavioral health.

Essential Functions:

• 50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references. Follows NCQA Standards, our Medical Policy, all guidelines, and departmental SOPS to manage member assignments. Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
• 30% Conducts research and analysis of pertinent diseases, treatments, and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider, and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities. Follows member contracts to assist with benefit determination.
• 20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level:

Bachelor's Degree

Education Details:

Nursing

Experience:

5 years Clinical nursing experience, 2 years Care Management

In Lieu of Education:

In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Preferred Qualifications:

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards.
• Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment, and the ability to confidently use the internet as a resource.

Knowledge, Skills and Abilities (KSAs):

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
• Must have strong assessment skills with the ability to make rapid connection with Member telephonically, Proficient
• Must be able to work effectively with large amounts of confidential member data and PHI, Expert
• Must be able to prioritize workload during heavy workload periods, Proficient
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint, Proficient
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis, Proficient

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required or
• LPN - Licensed Practical Nurse - State Licensure
• CNS-Clinical Nurse Specialist Preferred