4 Jobs in Ridge, IL
Group 1001 is Hiring an Utilization Management Specialist Near Ridge, IL
Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals. All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.Job Summary:Under the direction of the Utilization Management Team Lead, the Utilization Management Specialist is responsible for performing all utilization management activities to include reviewing, screening, processing and authorizing admissions, services, and Part B drugs requests from providers, members, and members’ representatives.
Main Accountabilities:
- Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, durable medical equipment (DME), Part B drugs, and outpatient and home health services.
- Monitors level and quality of care of services being provided and approved.
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- In conjunction with, and under the supervision of the Utilization Management Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans and available covered services including identifying alternative levels of care that may be covered.
- Monitors the Utilization Management system to assure compliance with turnaround time frames.
- Addresses care issues with Utilization Management Team Lead and Medical Director when appropriate.
- Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members.
- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly.
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members’ representatives, facilities, requestors, and service providers.
- Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames. Reviews all NON-certification files for correct documentation.
- Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Participates in the ICT meetings for the SNP membership.
- Performs other related activities as assigned.
- Licensed Registered Nurse
- Experience in the application of Milliman criteria or other evidence-based medical criteria.
- 2 – 4 years utilization review and/or managed care experience preferred
- Knowledge of medical problems encountered with Seniors.
- Working knowledge of Medicare Advantage Plans.
- Strong computer skills – Microsoft Office Suite
- Strong communication and interpersonal skills
- Ability to effectively present medical information one-on-one
Job Summary
Full Time
$148k-191k (estimate)
06/06/2024
07/14/2024
concretek.com
Ceiba, PR
<25
Related Companies
The job skills required for Utilization Management Specialist include Managed Care, Utilization Management, Discharge Planning, Microsoft Office, Collaboration, Coordination, etc. Having related job skills and expertise will give you an advantage when applying to be an Utilization Management Specialist. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Utilization Management Specialist. Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for Utilization Management Specialist positions, which can be used as a reference in future career path planning. As an Utilization Management Specialist, it can be promoted into senior positions as an Utilization Review Manager - Home Care that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Utilization Management Specialist. You can explore the career advancement for an Utilization Management Specialist below and select your interested title to get hiring information.
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