RN Team Lead-Utilization Management position at Magellan Health in Richmond

Magellan Health is at the momment seeking for RN Team Lead-Utilization Management on Sun, 20 May 2018 00:38:34 GMT. Can posses a Nurse Practioner license. RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt....

RN Team Lead-Utilization Management

Location: Richmond, Virginia

Description: Magellan Health is at the momment seeking for RN Team Lead-Utilization Management right now, this position will be situated in Virginia. Detailed specification about this position opportunity please read the description below.

Gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity c riteria. Collects and analyzes utilization information. Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria. Mentors new Utilization Management (UM) staff and assists with training.

ESSENTIAL FUNCTIONS:

• Provides point of need support and coaching to UM professionals and other clinical team members in the course of normal operations. Builds UM team members expertise through direct feedback and real-time coaching. Provides clinical, procedural or interpretational assistance.
• Mentors and trains UM staff. Serves as a ?buddy? to new UM Professionals during their first few months on the job by providing daily support and feedback, reviewing cases being recommended for approval by other UM nursing staff and aids inp presentation to Medical Director.
• Researches and res olves escalated issues that frontline UM professionals cannot resolve in a timely fashion. As necessary, takes escalated calls or fills-in for the UM team during high-peak periods.
• Works with the workforce planning team to perform data collection and analysis of trends to determine problem areas and strategies for better practices for the UM team.
• Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures.
• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
• Collaborates with the Car e Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
• Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
• Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
• Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
• Maintains an active work load in accordance with performance standard s.
• Advocates for the enrollee to ensure health care needs are met; Interacts with providers in a professional, respectful manner.
• Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

General Job Information

Title

RN Team Lead-Utilization Management

Grade

25

Job Family

Care Management

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

5/17/2018

Date Requisition Created

5/17/2018

Minimum Qualifications

Education

Associates: Nursing (Required)

License and Certifications - Required

RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

CCM - Certified Case Manager - Care Mgmt

Oth er Job Requirements

Responsibilities

Current Florida Medicaid experience., Post degree in a clinical, medical setting. Also requires minimum of 5 years of experience conducting utilization management according to medical necessity criteria., RN or clinical credentials in the medical health plan field. Can posses a Nurse Practioner license. Ability to use computer systems. Good organization, time management and verbal and written communication skills. Knowledge of medical utilization management procedures, Medicaid benefits, community resources and providers. Knowledge and experience in diverse patient care settings including inpatient care. Ability to function independently and as a team member.Knowledge of ICD and DSM IV coding or most current edition. Ability to analyze specific utilization problems and creatively plan and implement solutions.

Competencies

Language(s)

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

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This position will be started on: Sun, 20 May 2018 00:38:34 GMT