The Licensed Utilization Review I is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
Location: The ideal candidate will reside in Kentucky.
How you will make an impact:
Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
Applies clinical knowledge to work with facilities and providers for care coordination.
May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
Minimum Requirements:
Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Preferred Skills, Capabilities, and Experiences:
Knowledge of the medical management process strongly preferred.
