The Utilization Review Clinician for the QUEST population is responsible for the utilization management, utilization review and/or concurrent review of inpatient cases to determine medical appropriateness of inpatient and intermediate levels of care following clinical guidelines and benefit determination.
Utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical criteria, and benefit information and provide consultation and responses to utilization management requests. Complete clinical reviews and apply utilization review criteria for patient admissions and various levels of care and/or continued stay reviews and/or discharge planning. Participate in the identification of specialized clinical programs (new diversionary services) to address unmet needs in the network. Discuss cases with treating clinicians and other healthcare professionals as needed. Identify and monitor trends in utilization and quality metrics as needed. Collaborate with colleagues to establish workflows for overall management of high risk members including case management referrals, discharge planning and aftercare. Monitor productivity standards daily. Maintain thorough knowledge of covered benefits for the populations served. Participation in NCQA and URAC activities, as assigned. Other duties as assigned.
Demonstrated experience establishing relationships and effectively engaging with members and providers through telephonic communication to obtain necessary information and facilitate care in multiple settings. Demonstrated work experience applying analytic and critical thinking skills. Demonstrated work experience to influence and negotiate to effectively manage patient care and health care outcomes. Demonstrated work experience meeting strict deadlines and established cycle times through effective prioritization and follow-up skills.
Current, valid and unrestricted Hawaii licensure for practice required with proof on date of hire. Re-verification will take place no less than every 3 years.
Current, valid and unrestricted licensure for practice required with proof on date of hire. Re-verification will take place no less than every 3 years.
Required to be educated in current principles, procedures and knowledge of behavior health. They must be an independently licensed behavioral health clinician and practice within the scope of their licensure with a minimum of 10 years behavioral health /managed care experience
Beacon Health Strategies, LLC
Website : http://www.beaconhealthstrategies.com
In close partnership with health plans, we help bring together the fragmented pieces of healthcare to achieve better results for the people in our care. Our programs are clinically driven, fiscally responsible, and focused on continually improving outcomes for the most complex members.