Job Description
Role Description
- The CMI performs clinical/medical necessity reviews and authorizes medical services that meet medical criteria. The review of care is region specific and consists of:
- Outpatient healthcare services on pre-certification requests
- Outpatient procedures
- Outpatient services
- Elective inpatient admissions
- Home health services
- Genetic testing
- Orthotics
- Prosthetics
- Complex durable medical equipment
The CM1 also facilitates referrals to providers or vendors that are region specific while determining medical necessity and appropriateness.
- Qualifications
- 2 Years Experience in a medical setting (i.e. office, hospital, SNF, medical clinic etc.)
- California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians - REQUIRED
- Requirements
- Able to identify benefit coverage
- Assesses requests for services by first reviewing the patient's benefit under the health plan and the criteria of the health plan as to whether that service is covered.
- Reviews for medical necessity and appropriateness of services/care based on health plan members medical condition.
- Authorizes the correct vendor to provide care services reviewing risk matrix and health plan contracted vendor list.
- Communicates the decisions to the appropriate persons and documents per UM policy.
- Applies approved criteria to medical information.
- Consults with supervisor, team lead and/or medical director to discuss requests/care inconsistent to criteria and determine the appropriateness of service/care.
- Works closely with the Care Coordinators to obtain necessary information for clinical reviews for decision making.
- Documents per department policy in IDX, etc.
- Communicates decisions to the requesting provider, facility and member within department's approved guidelines.
- Communicate effectively, both orally and in writing, with all levels of management, medical staff and patients.
- Assist in conflict management and resolution as appropriate.
- Manage time effectively by applying organizational, critical thinking, analytical, patient care evaluation, and problem solving techniques.
- Identify and refer members to case management or quality management as appropriate for utilization or quality issues while maintaining department processes in compliance with the State and Federal standards.
- Reviews patients for multiple diagnoses, surgeries, age, inpatient/skilled nursing facility admits, repeat same type services for need for further management of health care.
- When a patient is suspected of need for further management, communicates this to the appropriate Case Management Program per UM policy.
- Gathers pertinent information to provide Case Management with knowledge of patient and issues.
- If patient is being managed by Case Management, discusses requests for services prior to authorizing additional services/care.
- Keeps current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, case management practice.
- Serves as a resource and mentor to regional team and other department staff.
- Establish mutually derived annual goals and meet goals.
- Maintain individual in-service/performance records.
- Attends and actively participates in department/team process/quality improvement activities.
- Authorizes medical care/services within specified turnaround times when pertinent information is available.
- Maintains turn-around time for routine, urgent and expedited referrals as outlined in SCMG's Utilization Management Plan.
- Documentation for reviews will occur as per policy IDX, etc.
- Benefits
- Hourly Pay Range (Minimum - Midpoint - Maximum): $34.170 - $44.090 - $49.370
- The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.
- The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
- Knowledge, Skills, and Abilities
- Knowledge of medical terminology, healthcare finances, alternative care options, utilization management, health plan criteria, established criteria such as MCG formerly known as Milliman Care Guidelines and its applications required.
- Knowledge and work experience in managed care preferred.
- Experience and knowledge of IDX modules and systems, proficient in use of ICD-10, CPT and HCPC coding systems required.
- Proficient in typing and computer data entry (45 wpm).
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