Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting.
Requirements
- Determines appropriateness and medical necessity of health care services provided to plan members.
- Supports plan utilization management program and accompanying action plan(s),
- Evaluates effectiveness of utilization management (UM) practices
- Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
- Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.
- Participates in and maintains the integrity of the appeals process, both internally and externally.
- Responsible for investigation of adverse incidents and quality of care concerns.
- Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications.
- Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams.
- Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
- Reviews quality referred issues, focused reviews and recommends corrective actions.
- Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
- Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer.
- Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process.
- Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.
- Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care.
- Ensures medical protocols and rules of conduct for plan medical personnel are followed.
- Develops and implements plan medical policies.
- Provides implementation support for quality improvement activities.
- Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed.
- Fosters clinical practice guideline implementation and evidence-based medical practices.
- Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management.
- Actively participates in regulatory, professional and community activities.
Benefits
- Competitive benefits and compensation package
