[Hiring] Utilization Management Specialist @Cynet Systems

Role Description

The role involves determining medical necessity and appropriateness by referencing various guidelines and policies. Responsibilities include:

• Determining medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, and accepted medical/pharmaceutical references.
• Following NCQA Standards, organizational Medical Policy, and departmental SOPs to manage member assignments.
• Conducting research and analysis of pertinent diseases, treatments, and emerging technologies.
• Collaborating with medical directors, sales and marketing, contracting, provider, and member services.
• Coordinating non-par provider/facility case rate negotiations.
• Making appropriate referrals and offering assistance to members and providers for alternative care settings.
• Researching and presenting educational topics related to cases to interdepartmental audiences.

Qualifications

• RN license, utilization management, computer skills.
• 5 years Clinical nursing experience.
• 2 years Care Management.
• In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required.

Requirements

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of organizational clinical guidelines, medical policies, and accreditation and regulatory standards.
• Working knowledge of organizational IT and Medical Management systems.
• Effective written and interpersonal communication skills.
• Strong assessment skills with the ability to engage with members telephonically.
• Ability to work effectively with large amounts of confidential member data and PHI.
• Ability to prioritize workload during heavy workload periods.
• Ability to multitask and maintain a dynamic personal organization system.
• Proficient in web-based technology and Microsoft Office applications.
• Excellent analytical and problem-solving skills.

Company Description