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General Purpose of Job:

The Utilization Management Case Manager is responsible for the coordination and efficient utilization of health care resources for the provision of quality care for all patients throughout the continuum of care.  The Case Manager will facilitate clinically appropriate and fiscally responsible patient care through communication with the providers and health plan medical directors, and all other members of the health care and health plan team.  The Case Manager assesses and identifies the patient’s clinical findings and determines, in conjunction with the Physician Advisor/Health Plan Administration, established benefits, protocols, pathways, and evidence based medicine tools the health care services and level of care appropriate for the patient.  Case Management can be prospective, concurrent, or retrospective. The Case Manager communicates with providers of care/services to ensure appropriate levels of care.

Essential Duties and Responsibilities:

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. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the Director, Utilization Management as required.

Utilization Review Case Manager’s Responsibilities:

Knowledge:

• Knowledge in Medicaid criteria/guidelines preferred. Knowledge about managed care contracts/guidelines preferred.
• Working knowledge of various reimbursement mechanisms, including third party requirements preferred.
• Current working and demonstrated knowledge of various criteria sets (i.e., InterQual) preferred.

Skills:

• Requires a well-organized individual with an excellent capacity for effective time management. 
• Demonstrates ability to establish and maintain effective working relationships with customers and peers.
• Demonstrates ability to operate personal computer programs as well as complex medical management software.
• Ability to understand complex situations and interpersonal dynamics so as to effectively handle escalated customer and co-worker needs.
• Strong Microsoft Office skills.
• Excellent communication skills.

Responsibilities:

• Participate in timely, quality completion of preauthorization or case management activities.
• Apply plan benefits consistently for each line of business.
• Identify members with health care needs for possible disease management programs available within the plan.
• Ensure appropriate referrals to other departments as necessary to include Case and Disease Management, Utilization Management, Social Services, Quality Management, Compliance and Provider Relations.
• Coordinate services as appropriate with community resources. Report suspected or actual  quality concerns, provider, eligibility, and compliance issues per policy. 
• Collaborate with physicians, social workers, nurses, and other multidisciplinary team members as appropriate to obtain optimal outcomes for members.
• Collaborate with hospital case managers to assure that impediments to safe discharge are recognized immediately and corrective action strategies are developed to ensure patient safety and maximize positive outcomes for the member and the organization.
• Complete concurrent and/or retrospective review for appropriateness of hospital treatment, using plan-approved evidence based criteria.
• Participate in health plan’s performance improvement activities.
• Participates in health plan committees as appropriate and on request.
• Participate in on-call scheduling as directed by management.
• Adhere to departmental and health plan policies.
• Accept other assignments from management as requested and comply with basic management principals of delegation.
• Communicate with management regarding status of current workload and turn-around-time discrepancies as necessary.
• Must obtain approval from manager or designee prior to any distribution of workload.
• Provides availability to non-clinical staff activities.

Education and/or Experience:

• Graduate of an accredited school of Nursing.  
• A minimum of three (3) years prior clinical experience.
• One year of acute inpatient case management or managed care case/utilization management experience preferred.