The position Title is for a Utilization Management Clinical Consultant. ( RN or LCSW only)
Job Description:
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Position Summary/Mission
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.
Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function (*)
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care(*)
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)(*)
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment(*)
• Identifies members who may benefit from care management programs and facilitates referral(*)
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*)
• Exhibits the following Manager Behaviours