[Hiring] Utilization Management Specialist @Ampcus Inc.

Role Description

The Utilization Review Specialist will perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Key responsibilities include:

• Utilizing key principles of utilization management.
• Analyzing clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements.

Essential Functions:

• 50% - Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
• 30% - Conducts research and analysis of pertinent diseases, treatments, and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
• 20% - Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care.

Qualifications

• Bachelor's Degree in Nursing.
• 5 years Clinical nursing experience.
• 2 years Care Management experience.
• In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required.

Requirements

• UM experience.
• RN/LPN state licensing or compact.
• Experience with Medicare Medicaid [Government Medicaid/Medicare Dsnap].
• Medicare and Medicaid background.
• Proficient with technology like computer, Windows, able to work independently.
• Clinical experience – 5 years.
• Nursing experience – Emergency background or critical care – nice to have.
• 2 years UM/care management – required.
• MCG required.
• GuidingCare – is must have.
• Facets knowledge is good to have.
• Manage 30-35 cases a day.
• DMV candidate can be considered - license for MD is required.

Company Description

Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services.