All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members.
Must Have Skills
Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelines..
Please ensure that candidates have experience with actually reviewing for Medicaid/ MLTC members not Medicare or IP reviews as those are very different with a different workflow and process. Candidates must be aware that this is a fast-paced environment with a Turn around Timeframe of 3 business days on average for our std requests as we do not get many urgent/expedited requests.
Day To Day Responsibilities
All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews.
Required Years Of Experience
At least 1-2 years experience in UM.
Required Licensure / Education
Licensure required is a NY State License Practical Nurse or Registered Nurse -LPN NY & NY RN
Summary
Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing care members with the right care at the right place at the right time.
Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Essential Functions
Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team.
Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care.
Maintains department productivity and quality measures.
Attends regular staff meetings. Assists with mentoring of new team members.
Completes assigned work plan objectives and projects on a timely basis. Maintains professional relationships with provider community and internal and external customers.
Conducts self in a professional manner at all times.
Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
Consults with and refers cases to Molina medical directors regularly, as necessary.
Complies with required workplace safety standards.
Knowledge/Skills/Abilities
Demonstrated ability to communicate, problem solve, and work effectively with people.
Excellent organizational skill with the ability to manage multiple priorities.
Work independently and handle multiple projects simultaneously.
Knowledge of applicable state, and federal regulations.
In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
Experience with NCQA.
Ability to take initiative and see tasks to completion.
Computer Literate (Microsoft Office Products).
Excellent verbal and written communication skills. Ability to abide by Molinas policies.
Ability to maintain attendance to support required quality and quantity of work.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
Required Education
Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree).
Required Experience
Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management. Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
Employee Benefits
At LanceSoft, full time regular employees who work a minimum of 30 hours a week or more are entitled to the following benefits:
Four options of medical Insurance
Dental and Vision Insurance
401k Contributions
Critical Illness Insurance
Voluntary Permanent Life Insurance
Accident Insurance
Other Employee Perks
About LanceSoft
LanceSoft is rated as one of the largest staffing firms in the US by SIA. Our mission is to establish global cross-culture human connections that further the careers of our employees and strengthen the businesses of our clients. We are driven to use the power of our global network to connect businesses with the right people, and people with the right businesses without bias. We provide Global Workforce Solutions with a human touch.
EEO Employer
LanceSoft is a certified Minority Business Enterprise (MBE) and an equal opportunity employer. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. LanceSoft makes hiring decisions based solely on qualifications, merit, and business needs at the time.
Seniority level
Entry level
Employment type
Internship
Job function
Health Care Provider
Industries
IT Services and IT Consulting
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