Utilization Management Job at KMM Technologies, Inc. in Baltimore

Position: Utilization Management
Location: Baltimore, MD #REMOTE (Should come to the office for training)
Duration: Long term

Job Description:

• Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage.
• Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.
• Education Level: Bachelor's Degree (Nursing)
• 5 years Clinical nursing experience and 2 years Care Management
• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards
• Working knowledge of CareFirst IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.
• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
• Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient
• Must be able to work effectively with large amounts of confidential member data and PHI, Expert
• Must be able to prioritize workload during heavy workload periods, Proficient
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient

Top 5 Required Skills:

Utilization Management experience, Knowledge of Milliman Care Guidelines.

Licenses/Certifications

RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or
LPN - Licensed Practical Nurse - State Licensure
CNS-Clinical Nurse Specialist

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards
• Working knowledge of CareFirst IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource

ESSENTIAL FUNCTIONS:
50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Thanks & Regards,
--
LAXMAN
KMM Technologies, Inc.
CMMI Level 2 | ISO 9001 | ISO 20000 | ISO 27000 Certified
WOSB, SBA 8(A), MDOT MBE & NMSDC MBE
Tel: (240) 800-0039 |Email: lax@kmmtechnologies.com