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About the Role

This position is responsible for coordinating, integrating, and monitoring the utilization of behavioral health (BH) or physical health (PH) services for members, ensuring compliance with internal and external standards. It involves referring cases to the Medical Director and collaborating with Case Management to address member needs. The role may require participation in a rotating on-call schedule and potentially additional hours.

Responsibilities

Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members’ behavioral health conditions.
Applies established clinical review criteria, guidelines, medical policies, contractual benefits, and State and Federal Mandates.
May perform clinical review telephonically, electronically, or on-site.
Plans, implements, and documents utilization management activities.
Ensures compliance with corporate and departmental policy and procedure.
Identifies and refers potential quality of care and utilization issues to Medical Director.
Utilizes appropriate communication techniques with members and providers to obtain clinical information.
Assesses medical necessity of services and advocates for members in obtaining needed services.
Interacts with the treating physician or other providers of care.
Collaborates with hospital, home care, care management, and other providers effectively.
Acts as a resource and liaison to the provider community.
Makes accurate and consistent interpretation of required clinical criteria, medical policy, contract benefits, and State and Federal Mandates.
May be responsible for pricing, coding, and researching claims.
Accountable for meeting departmental guidelines for timeliness, production, and metrics.
Meets requirements established for audits to ensure adherence to regulatory and departmental policy/procedures.
Maintains compliance with all regulatory and accrediting standards.
Keeps abreast of changes and is responsible for implementation and monitoring of requirements.
Assists with training and special projects, as assigned.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
Offers process improvement suggestions and participates in the solutions of more complex issues/activities (Level II).
Mentors staff and assists with coaching (Level II).
Provides consistent positive results on audits (Level II).
Works independently in coordinating and collaborating with members and providers (Level II).
Manages more complex assignments and is cross-trained to review various levels of care and/or services (Level II).
Participates in committees and leads when required (Level II).
Displays leadership and serves as a positive role model (Level III).
Identifies, recommends, and assesses new processes to improve productivity and gain efficiencies (Level III).
Assists in updating departmental policies, procedures, and desk level procedures (Level III).
Serves as subject matter expert for escalations and resolves issues (Level III).
Provides guidance and leadership to the daily activities of the Utilization Management Department clinical staff (Level III).
Acts as resource to Utilization Management staff, members and providers (Level III).
Provides backup for the Supervisor, whenever necessary (Level III).
Participates in the orientation of new staff and/or training opportunities for all staff (Level III).
Assists staff to identify opportunities to successfully engage members into care (Level III).
Assists Medical Director (MD) in projects as needed (Level III).

Requirements

Associates degree and active NYS RN license required.
Bachelors degree preferred.
Minimum of three (3) years of clinical experience required.
Utilization Management experience preferred.
Must demonstrate proficiency with the Microsoft Office Suite.
Demonstrates general understanding of coding standards.
Maintains current and working knowledge of Utilization Management Standards.
Experience in interpreting managed care benefit plans and strong knowledge of government program contracts (Medicare and Medicaid) and benefits, preferred.
Strong written and verbal communication skills.
Ability to multitask and balance priorities.
Must demonstrate ability to work independently on a daily basis.
Deliver efficient, effective, and seamless care to members.
Minimum of 2 years in utilization management position (Level II).
Demonstrates ability to escalate to management, as necessary (Level II).
Demonstrates proficiency in all related technology (Level II).
Ability to take on broader responsibilities (Level II).
Ability to participate in training of new staff (Level II).
Must have been in a utilization management position or similar subject matter expert for at least 5 years (Level III).
Broad understanding of multiple areas (i.e. UM and CM) (Level III).
Expert in Utilization Management and ability to handle complex assignments, challenging situations and highly visible issues (Level III).
Ability to lead the training of new staff (Level III).
Demonstrated presentation skills (Level III).
Ability to independently travel within regions.
Ability to work at a computer for prolonged periods of time.

Skills

Behavioral health services
Physical health services
Clinical reviews
Utilization management
Microsoft Office Suite
Coding standards
Managed care benefit plans
Government program contracts (Medicare and Medicaid)
Written communication
Verbal communication
Multitasking
Prioritization
Independent work
Care delivery
Process improvement
Mentoring
Coaching
Technology proficiency
Presentation skills

Location

Remote (potential)

Work Type

Full-time

Experience Level

Level I
Level II
Level III

Education Level

Associate's degree
Bachelor's degree preferred
NYS RN license

Salary/Compensations

$62,400 - $96,081 (E2)
$62,400 - $106,929 (E3)
$65,346 - $117,622 (E4)

Benefits

Group health and/or dental insurance
Retirement plan
Wellness program
Paid time away from work
Paid holidays

About the Company

The Lifetime Healthcare Companies

Equal Opportunity

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.