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UM Clinical Specialist II (RN)**
- Job Title
- UM Clinical Specialist II (RN)**
- Job ID
- 531257
- Begin Date
- 3/5/12
- Duration
- Location
- Miramar, FL,
- Other Location
- Description
-
It's the new age of independence. And it's changing the way we live.
BE PART OF IT.UNIVITA is dedicated to helping people live and age with independence. By providing a single place to find and manage resources which support independent living, UNIVITA makes it easier to access care and to age safely at home.
This is your opportunity to join an innovative company with a culture that promotes compassion, trust, and accountability.
JOB SUMMARY: This position will be responsible for clinical oversight for reviewing requests for coverage of benefits and/or medical necessity either pre or post service. This position may work with providers to educate them on general aspects of Utilization Management (UM) processing. This position may also support the beneficiary/family regarding their benefits, educating them about their benefits and the programs offered by Univita. This position may work closely with the claims payer to ensure proper claims payment based on the authorization or denial. This position will have a role in identification of candidates for referral to other programs.
Essential Functions- Reviews accurately all directions per Medical Doctor (MD) orders and coordinates all request for services and care as per contractual arrangements, policy and workflow for coverage of benefits and/or medical necessity both pre or post service and verification of eligibility for types of services as per Health Plan specific direction.
- Interprets medical policy and benefit plan descriptions for covered and medically appropriate benefit decisions. Uses available resources and guidelines (including but not limited to Health Plan contractual arrangements, Medicare, Medicaid, Millimen guidelines) and other clinical resources, guidelines/ criteria as needed.
- Promotes network provider compliance and quality home health care.
- Processes Fee for Service (FFS) requests and compiles a recommendation summary with all paperwork to be submitted to the health plan. Also, maintains the authorizations/ certifications for services are obtained for FFS clients and submits clear, accurate and complete documentation with certifications to Provider network.
- Processes all wound care and pharmacy supply requests received by provider network to vendors as directed and coordinating all care.
- Provides timely communication with providers and the claims payer regarding authorizations and/or denials or additional documentation needs per customer agreements related to service level expectations.
- Processes beneficiary /patient referrals to provider network, all certifications determined by scripted entry. Staffing cases with appropriate discipline and Agency per Univita network direction and drop down menu choices plus requests additional clinical information from Network Providers where applicable. i.e.: updated Physician order and /or complete medical records
- Submits clear, accurate and complete documentation to provider network while keeping all records up to date and accurate in designated systems and following up on visit completion.
- When applicable, completes research regarding beneficiary history prior to determination. Completes appropriate documentation in designated systems for all reviews.
- Refers research and other cases that do not meet guidelines and / or criteria to second level review nurse and / or therapeutic specialist per department guidelines.
- Evaluates needs of beneficiary / patients and refer to other programs. Makes recommendations to Providers, beneficiary/ patient for Community Resources when applicable.
- Provides oversight to non-clinical staff for guidance and review for the pre-screening process for precertifications.
- Responsible for meeting daily production and turnaround times and all contractual arrangements plus handle any provider/beneficiary/ health plan calls.
- Provides availability as a resource to Providers, Health plans, other staff and referral sources while educating & supporting the Utilization Management Program.
- Participates in on-call, after hours, weekend and holiday support for the department as scheduled.
- Participates in performance improvement activities, staffing meetings, all training activities, committee work to promote the Quality Improvement (QI) program and other department or company activities.
- Maintains confidentiality and respect of Patient information in accordance with HIPPA, URAC and company standards, policy and procedures.
- Monitors and reports Network availability, quality concerns or utilization trends and reports to supervisor in a timely manner. This position may involve review of appeals and responding to health plan inquires as needed.
- Proficient in several areas of Utilization Management (UM) processing and support of including claims, appeals for medical, transportation and pharmacy, Hold Harmless, and grievances to assist as needed.
- Provides leadership and development of customer special programs.
- Assists Lead/Supervisor with monitoring daily production and turnaround times for Utilization management, Claims, Pre-certifications, Appeals, Grievances, Hold Harmless cases and other items. This includes mentoring, training and providing assistance to other UM Clinical Generalists and Staffing Coordinators when the Lead or Supervisor is not available.
- Provides availability as a resource for staff to review any cases that do not meet medical necessity guidelines before sending to medical director/consultant for review.
- Provides back up support for field calls from Health plan and others regarding system and process questions, research answers and follow up within 24 hours for a timely response.
- Researches latest Medicare and Medicaid guidelines and notifies the supervisor if changes need to be made to current policies and procedures.
- Handles any escalated provider, beneficiary, or health plan calls if lead or supervisor not available.
- Interfaces with the other departments for any Utilization Management (UM) questions.
- Monitors utilization trends and Patient outcomes and reports to supervisors and Providers if any instances do not meet Univita’s Utilization Management Program.
- All clinical decision supervision will report to the next level of RN Management within the department structure
- Other duties as assigned.
Minimum Requirements- Established critical thinking including problem solving, decision making, and clinical judgment skills required.
- Ability to prioritize and effectively handle multiple tasks.
- Organized, detail-oriented.
- Working knowledge of Windows.
- Working knowledge of computerized medical management systems and or web based computer programs.
- Clinical education to receive a licensed clinical nursing certificate.
- Must maintain a current, valid and unrestricted Florida LPN/ LVN license and other states as required.
- At least 4 years clinical work experience preferably with older adult population in a community setting or long-term care facility or previous managed care or home health experience.
- Required to uphold the principles of compliance as outlined in the Code of Conduct, Employee Handbook and related policies and procedures. Supports and participates in the mandatory Corporate Compliance Program training initiative on an annual or more frequent basis, as required.
- Must maintain a current, valid and unrestricted Florida RN license and other states as required.
- Openings
- 1
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Univita Health is an Equal Opportunity Employer (EOE/AA) and participates in E-Verify. Univita Health will not discriminate in its employment and employment-related decisions against any applicant or employee based on age, race, gender, creed, religion, national origin, disability, marital status, covered veteran status, sexual orientation, status with respect to public assistance, membership or activity on a local commission, or any other characteristic protected under state, federal, or local law.
