Ltss Utilization Management Reviewer Clinical Jobs

Demonstrated experience in utilization management, discharge planning, or transfer coordination.

Previous case management experience preferred.

Must be able to work in a Labor/Management partnership environment.

Bachelors degree in nursing or health related field OR four (4) years of experience in a directly related field.

High School Diploma or General Education Development (GED) required.

Knowledge of Nurse Practice Act, TJC, and other federal/state/local regulations.

3+ years combined clinical and utilization management experience

Experience with utilization management platform preferred

Knowledge, Skills & Abilities Required:

Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

3+ years' experience working in a health plan preferred

Strong collaboration and negotiation skills

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.

Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

Verifies and documents Participant eligibility for services.

Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

Do you value care management and quality improvement?

Are you an experienced Clinical Reviewer looking for a new challenge?

Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.

Active unrestricted RN applicable State and/or Compact State clinical license per contract requirements.

Knowledge of current NCQA/URAC standards strongly preferred.

Medical record abstracting skills required.

Utilization of clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members

Identification of members who may benefit from care management programs and facilitation of the referral

1+ year(s) of utilization management experience within a managed care organization

Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization

5+ years of clinical experience as a Registered Nurse

Case Management Certification (CCM) preferred within first year of eligibility.

Prior Utilization Management experience is preferred.

Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.

Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.

Has three to five years of experience working in a hospital.

Demonstrates strong critical thinking and problem-solving skills.

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

Verifies and documents Participant eligibility for services.

Accesses and applies Medical Necessity Guidelines for decision making.

Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)