Summary
Reporting to the Outpatient Lead Clinician, the OP UM Clinician, Retrospective Review is responsible for assuring thorough outpatient retrospective review for all referrals without prior authorization.
The OP UM Clinician, Retrospective Review works closely with Medical Director to determine and ensure high-quality medical outcomes.
Duties and Responsibilities:
Review and process retrospective review for medical necessity, escalating referral to the Medical Director when additional expertise is required
Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
Promote improved quality of care and/or life
Prevent hospitalization when possible and appropriate
Provide for continuity of care
Ensure appropriate levels of care are received by members
Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business
Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers
Identify complex authorization requests and appropriately refer to Case Management personnel
Communicate and collaborate with Providers to collect member information/medical records that supports and justifies decisions regarding retrospective review
Work effectively with Claims Department and all other sub team members within Outpatient UM
Maintain prompt and open communication with Notice of Action (NOA) Team
Communicate with Health Plan Liaisons in the event that a retrospective review requires health plan review, ensuring review is completed in compliance with timeliness standards
Outreach to Provider Network Operations (PNO) Team to address provider related referral insufficiencies
Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources
Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.
Maintain knowledge of UM policy and procedures
Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians
Minimum Job Requirements:
Current California RN or LVN license
2+ years of experience in utilization management preferred
Proficiency with Microsoft Office Programs; primarily Word and Excel
EZ-CAP® knowledge a plus
Skills and Abilities:
Excellent relationship management skills with the ability to communicate effectively with all stakeholders
Strong organizational, task prioritization, and delegation skills
Ability to collaborate successfully with all levels of the organization
Salary Range:
LVN $32 - $38 per hour
RN $39 - $43 per hour
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