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Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Review. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

2. Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

2. Medical Management for Medicare and/or Medicaid populations.

3. Utilization Review experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.

2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.

3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.

4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.

5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.

6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.

7. Understands the data that is collected within the position, and work with other team members on improving outcomes.

8. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

Attention to detail.

5. Proficiency with Microsoft Office.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

2. Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

2. Medical Management for Medicare and/or Medicaid populations.

3. Utilization Review experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.

2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.

3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.

4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.

5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.

6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.

7. Understands the data that is collected within the position, and work with other team members on improving outcomes.

8. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

Attention to detail.

5. Proficiency with Microsoft Office.

Remote Position

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PHH Medical Management

Address:

1085 Van Voorhis Rd

Morgantown

West Virginia