| Department: |
Medical Management
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| Level: |
Non-supervisory
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| Reports To: |
Manager, Utilization Management
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| Private Health Information (PHI): |
Position requires "read and write" access to member authorizations, "read only" access to claims and eligibility
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| Job Classification: |
Non-Exempt
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| Job Type: |
Full time - Four-Day 10 hour days, Monday - Thursday |
| Pay Rate: |
Salary is based on qualifications and experience |
| Position Summary: |
Reviews contracted Medical Group’s referral requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed decision. Processes all requests within established timeframes. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters.
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| Essential Job Functions: |
This description is not exhaustive and may be modified on a temporary or regular basis at the discretion of SCPMCS. SCPMCS expects that its' employees will need to assume other "non-essential functions" not listed herein which support company business objectives; this may include duties which fall outside of normal position scope
Reviews contracted Medical Group’s referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizing contracted providers. Documents process in authorization notes
Refers all medical necessity denials to the physician reviewers for review determination. Processes denials within established time frames. Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available.
Reviews requests within established time frames for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards.
Obtains additional information for Medical Director’s review of appeals. Coordinates with health plan to meet time frames for expedited appeals.
Contacts out of network or tertiary facilities for clinical information on patients authorized for services at the facility. Coordinates discharge needs for these members with hospital case manager.
Notifies health plan representative of potential transplants, out of area second opinions, experimental or investigatory requests.
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| Position Qualifications and Requirements: |
Experience/Specialized Skills: Prior experience in utilization management in a managed care environment. Proficient with computer, Microsoft Windows environment.
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| Education/Course(s) /Training: |
Registered Nurse
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| Licensure/Certification: |
Registered Nurse, active California License. Must have reliable transportation, valid California Driver's License and proof of insurance.
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| Location: |
Mira Mesa, San Diego |
| Date Posted: |
October 13, 2021 |
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To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org |
