[Hiring] Utilization Review 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. Leveraging clinical expertise and critical thinking skills, the specialist will analyze:

• Clinical information
• Contracts
• Mandates
• Medical policy
• Evidence-based published research
• National accreditation
• Regulatory requirements

This role is essential in contributing to the determination of appropriateness and authorization of clinical services, both medical and behavioral health.

Qualifications

• Minimum 5 years of clinical nursing experience
• Background in critical care or managed care
• Prior knowledge of managed care and utilization review
• Proficiency with MCG guidelines
• Active compact RN license or Maryland RN license
• Strong knowledge of Microsoft applications
• Experience with both Facets and Guiding Care (mandatory)
• Bachelor's Degree in Nursing
• 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

• 50% - Determines medical necessity and appropriateness by referencing:
• Regulatory mandates
• Contracts
• Benefit information
• Milliman Care Guidelines
• Apollo Guidelines
• ASAM
• Medicare Guidelines
• Federal Employee Program and Policy Guidelines
• Medical Policy
• Other accepted medical/pharmaceutical references
• 30% - Conducts research and analysis of pertinent diseases, treatments, and emerging technologies, including:
• High cost/high dollar services
• Collaborates with medical directors, sales and marketing, contracting, provider and member services
• Applies sound clinical knowledge and judgment throughout the review process
• Coordinates non-par provider/facility case rate negotiations
• Follows member contracts to assist with benefit determination
• 20% - Makes appropriate referrals and contacts as appropriate:
• Offers assistance to members and providers for alternative settings for care
• Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences

Company Description