Your Role
The Federal Employee Program (FEP) teamis committed to providing quality healthcare coverage to federal employees, retirees, and their family. The FEP Utilization Management Nurse Consultant (Lead) will report to the FEP Utilization Management Medical Review Manager. In this role you will bepart of a dynamic team responsible for prior authorization, concurrent, and post service medical reviews. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit. Ultimately contributing to decreasing the cost of healthcare.
Your Work
In this role, you will:
- Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using FEP and BSC evidenced based guidelines, policies and nationally recognized clinal criteria.
- Conduct clinical review of prior authorization, concurrent, and post service requests for medical necessity, coding accuracy, medical policy compliance and contract compliance.
- Ensuredischarge(DC) planning at levels of care appropriate for the members needs.
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationand communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
- Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standardsand identifypotential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
- Provide referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
- Actively participate in staff meetings and huddles.
- Provide input into desk level procedures, and precept new employees.
- Perform monthly clinical staff audits for the concurrent review clinical teams and generally, responsible for providing guidance, coaching, and training to other employees within job area.
- Act as a tester for the UM documentation system and sign-off the system for production
- Generally, responsible for providing guidance, coaching, and training to other employees within job area.
- Provide clinical coverage for preservice, concurrent review, and post service as needed for vacations, sabbaticals, leave of absences, and periods of high caseloads.
- Collaborate with leadership on special projects as assigned.
Your Knowledge and Experience
- Requires a bachelor's degree or equivalent experience
- Requires a current California RN License
- Requires at least 7 years of prior relevant experience
- Previous experience in utilization management preferred
- Strong computer skills related to Windows-based programs and applications
- Varied acute care clinical background
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
- Strong clinical documentation skills, independent problem identification and resolution skills
- Excellent analytical and problem-solving skills
- Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)
- Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision
- Work is performed with limited oversight