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Posted: Wednesday, June 21, 2017 12:46 PM

Position Summary: Responsible for performing WorkerA?s Compensation utilization review which includes prospective, concurrent, expedited and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence based criteria. Through the discharge planning process, identify patients who have ongoing case management needs and refer these members to the Case Management team for outreach and follow up. Essential Duties and Responsibilities: Conducts prospective, concurrent, expedited and retrospective utilization management, including inpatient services, outpatient services, surgeries and ancillary service requests.Reviews all requests for treatment in accordance with preauthorization criteriaEvaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity and refer to the Medical Director if appropriate within the state jurisdiction timeframesReview length of stay for inpatient cases when applicable; Arrange alternative care services/discharge planningConsult with the Medical Director as needed to review complex cases Promote cost effective health care with aligned health provider network Additional Functions and Responsibilities Demonstrates ability to meet administrative requirements, including productivity, time management and Quality Assurance standards Maintain minimum billing and established template documentation standards adhering to URAC standards and company policies and proceduresReporting billing hours in accordance with case activity and billing practicesMaintain confidentiality: Knowledge of laws and regulations pertaining to HIPPA and PHIOther job duties as assigned Education: Diploma, Associate or BachelorA?s degree in Nursing, MasterA?s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferredCurrent, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license requiredCCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred Experience: 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. Three or more years of diverse clinical experience in acute care Two or more years of Utilization Review or Managed Care experience, WorkerA?s Compensation background preferredKnowledge of utilization management, quality improvement, discharge planning, and or cost management. Ability to solve practical problems and deal with a variety of variables. Possess planning, organizing, conflict resolution, negotiating and interpersonal skills. Excellent interpersonal skills and excellent organizational skills.Ability to set priorities and work independently is essentialProficient with Microsoft Office applications including Word, Excel, and Power Point EQUIPMENT OPERATED/USED: Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, MouseEssential Tools: Pens, pencil, computer, Keyboard Essential Vehicles: N/ASPECIAL EQUIPMENT OR CLOTHING: Professional attire adhering to the Company Dress Code


• Location: North DFW

• Post ID: 56946278 northdfw is an interactive computer service that enables access by multiple users and should not be treated as the publisher or speaker of any information provided by another information content provider. © 2017