Job Description
The Pre-Cert Nurse will review clinical documentation to determine the medical necessity of requested services by providers and members, and will approve when medical necessity and approved criteria are met. Assist Medical Director in the organizational determination for services that do not meet medical necessity. The pre-cert nurse will follow UAM policies and procedures regarding Organizational Determination guidelines and timelines.
Responsibilities:
- Reviews service requests submitted by physicians to include review of evidence/clinical documentation and its medical necessity.
- Facilitates provider contact as needed to coordinate member’s care needs.
- Assess as needed the discharge planning needs regarding Home Health and/or elective procedures. Coordinating with facilities, Medical Management staff, providers and members.
- Consults and works closely with the Medical Director regarding care that doesn’t appear to meet medical necessity.
- Responsible for the documentation of all clinical decisions, to include the drafting and recording of denial letters to providers and members.
- Conducts daily tracking of caseload as assigned.
- Complies with all departmental policies and procedures.
- Participates in departmental and company in-services as appropriate.
- Complies with Customer Service expectations as applicable to the Department and Health Plan.
- Assist in retroactive reviews done for the Claims department.
- Take calls from members and providers and give them appropriate information to help expedite services.
- Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies.
- And all other duties assigned by the manager and/or supervisor.
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Required Skills
- Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
- Organizational skills with the ability to handle multiple tasks and/or projects at one time.
- Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company.
- Analytical and interpretation skills including departmental, utilization, financial and operations data.
- Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization.
- Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements.
- Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
- Problem solving skills with the ability to look for root causes and implementable, workable solutions.
- Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs.
- Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization.
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Required Experience
- LVN with current Texas licensure.
- Utilization management within a hospital, Insurance, managed care company is required.
- Bilingual and experience with seniors, aged, blind and disabled is a plus.
- Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum.
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| Work Environment / Physical Demands: |
Work is performed in a professional office setting, business casual dress environment. Working extended hours may be required as needed.
The physical demands for this position include exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently to lift, carry, push, and pull or otherwise move objects, including the human body. This is considered sedentary work, which involves sitting most of the time; walking and standing are required, as well on occasion. Telephone work and/or computer work are typically required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Universal American Corp. is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce. |
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