US Jobs US Jobs     UK Jobs UK Jobs     EU Jobs EU Jobs


This job has been posted for more than 30 working days and has expired.

UM Specialist II


UM Specialist II - San Antonio, TX
LVN or RN position
Position Summary
Responsible for coordination of daily UM functions in accordance with Molina Healthcare of TX policies and procedures.

Coordinates decisions for all services requiring a medical necessity review including: inpatient and outpatient hospital services, diagnostic testing, equipment, home health care, and high cost injectable drugs.

Functions as a clinical resource for other non-licensed UM staff.

Interacts with the Medical Directors, Molina staff and providers in a professional manner to ensure the delivery of high quality, cost effective healthcare services for Molina members.
Duties and Responsibilities
Reviews clinical information provided with request and determines if it meets UM criteria.

If meets medical criteria will authorize service(s) and enter clinical data and authorization services appropriately in QNXT.

Maintains familiarity with plan benefits, in order to facilitate interpretation.

Demonstrates the ability to apply critical thinking and independent judgment skills.

Notifies provider decision regarding request.
Meets current departmental established Productivity standards.
Requests additional information from providers, per policy, when clinical information does not reflect need for requested services, based on medical criteria.

Actively pursues additional sources of information as needed.

Uses internal resources appropriately.
Reviews clinical information for cases that do not meet criteria.

Prepares a detailed, organized analysis of information provided, as well as information requested but not yet obtained, uses template, and escalates requests to the Medical Director for determination.

Initiates effective and timely physician interface.
Processes service requests in compliance with Molina turnaround timeframe policies.

Follows department timeframes in all aspects of auth processing.
Meets department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.

Expectation is obtainment of score ≥95% for IRR and average of ≥95% for all quarterly review scores after 90 days of employment.
Provides excellent customer service (including internal and external customers) to ensure excellent service to our members and physicians in all aspect of their medical care delivery and reimbursement.

Includes appropriate Referrals to Complex Case Management, DM, SSI, & QI per Molina policy.
Performs other duties including but not limited to:
Able to review multiple service request types;
Assists with UM telephone queue coverage during times of high volume;
Mentors new staff as directed by supervisor;
Acts as a resource as directed by supervisor.
Adheres to departmental standards of confidentiality of medical and proprietary information.
Participates in continuous quality improvement activities including participation in Utilization Management meetings as an active member of the team
Meets attendance guidelines per Molina Healt...

 


More Jobs from Molina Healthcare