FirstHealth of the Carolinas
Pinehurst, NC, USA
The Utilization Management Coordinator is a Registered Nurse responsible for ensuring requests for specific health care services are medically necessary. Using evidence-based clinical criteria and severity of illness/intensity of service criteria, the Utilization Management Coordinator reviews the telephonic, faxed, e-mailed, online and written requests to ensure the services meet criteria, and approves those that do, notifying certain parties of such authorization and certification by methodologies and timelines appropriate for the request. The Utilization Management Coordinator refers those requests which do not meet criteria to the Medical Director. The Utilization Management Coordinator also identifies situations whereby a referral to Case Management, Disease Management or care coordination is appropriate. This position will be working more closely with PreCerts. Additional duties/responsibilities include: Development, updates and maintenance of Medical Policies and procedures Appeals and grievance coordination activities Performing research to determine coverage of new technologies, drugs and services. Current, active fully-licensed North Carolina Registered Nurse or Compact State nursing license, with a Baccalaureate degree in nursing required. Knowledgeable on application of Medical Necessity principles, procedures and criteria. Minimum of 3-5 years of recent clinical experience, preferably involved with care management, discharge planning, or home health care. Experience in reviewing health care services for medical necessity in a clinical setting or in a utilization management role or similar activities required. Knowledge of the managed care industry, health benefits industry, and N.C. insurance laws needed. Familiarity with requirements of accrediting bodies such as NCQA or URAC preferred. Detail-oriented and excellent communicator. Excellent documentation skills and time management a must. Must work well with physicians and all other health care providers. Must be comfortable using various clinical and Microsoft applications. NC Drivers license and reliable transportation necessary.