Clinical Review Prior Authorization UM Specialist

HealthPartners is hiring a Clinical Review Prior Authorization Specialist.

POSITION PURPOSE:

Accurate application of HealthPartners evidence-based coverage criteria in alignment with member benefit plan

Appropriate management of HealthPartners fiduciary responsibilities in alignment with employer expectations

Responsible for making accurate coverage determinations for the patient that are timely, reliable, accurate, and consistent.

Serve as subject matter expert on complex utilization management issues for internal and external customers.

ACCOUNTABILITIES:

• Maintain an understanding of state and federal regulations, accreditation standards, HealthPartners products and networks, member contracts and Health Plan policies and procedures related to Utilization Management
• Investigate and respond to complex, high profile, and/or escalated customer questions, issues, and requests. Contact members and/or providers to ensure accurate understanding of the situation.
• Responsible for accurately interpreting coverage criteria and making correct determinations and communicating relevant information to providers and members.
• Responsible for accurately interpreting and correctly applying benefits, networks, and product variances; and clearly communicating to members, providers, and internal departments.
• Facilitate utilization management and assist in answering questions as part of the claims adjudication process.
• Responsible for preparing documentation and consulting with the Medical Director for all potential denials that do not meet medical necessity or HealthPartners criteria. The decision for a medically necessary denial is within the Medical Director role.
• Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions, and rationale to facilitate resolution in compliance with all regulatory requirements
• Utilize member contracts, coverage criteria, and procedures, Medical Directors, and other resources in the decision-making process.
• Facilitate communication between physicians, providers, members, and medical directors/other administrative staff to achieve consensus for coverage decisions.

Relationship & Team Building:

Promote a positive, effective, and efficient work environment and cross-functional team approach.

Ensure all staff, processes and programs are customer-focused resulting in high levels of customer, member/patient/family, colleague, and team member satisfaction.

Embrace change. Support an environment that encourages creativity, independence, and willingness to change.

Develop and maintain positive, effective working relationships with colleagues, Medical Directors, providers, vendors, and other customers.

Function as a trainer and mentor for new staff members as requested by Leadership.

Knowledge & Education:

Maintain knowledge of, and effectively use automated applications and systems and applicable software.

Participate in ongoing independent study and education to develop and maintain knowledge in the areas of applicable software systems, regulatory and accreditation standards, quality improvement strategies, as well as on-boarding and training techniques.

Maintain a thorough and comprehensive understanding of state and federal regulations, accreditation standards and member contracts in order to ensure compliance.

Customer Service:

Consistently apply HealthPartners organizational and department values (mission/vision/values), and continuous quality improvement principles in relationships, daily work, and customer interactions.

Responsible for accurately interpreting and correctly applying benefits, networks and product variances and clearly communicating such to members, providers, and internal departments.

Act as a liaison between internal and external customers, Marketing, Sales, Claims, Member Services, Nurse Navigators, and clinics to resolve systems/process issues.

Collaborate with physician consultants and Medical Directors to ensure consistent and comprehensive coverage decisions.

Communication:

Efficiently and accurately communicate coverage decisions to members, providers, and medical groups, following timelines established by regulations and accreditation standards.

Identify and appropriately inform Manager/Supervisor of sensitive or complex cases.

Able to negotiate, resolve or redirect when appropriate issues pertaining to differences in expectations of coverage, eligibility, and appropriateness of treatment recommendation.

Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI.

Demonstrate responsiveness to, and appreciation of constructive feedback and recommendations for personal growth and development.

Respond to Member Appeals and MDH (Minnesota Department of Health) inquiries as requested by the Appeals area.

Perform other duties as assigned.

REQUIRED QUALIFICATIONS:

Currently licensed Registered Nurse.

Minimum of three years clinical practice experience as an RN in medical/surgical, critical care, home care, or equivalent knowledge of current hospital and clinical care processes.

Clear and concise verbal and written communication and interpersonal skills.

Ability to use critical thinking skills for problem solving.

Ability to organize and prioritize multiple assignments within workload

Ability to function independently and take independent action, within the scope of job responsibilities.

Competency in personal computer skills including Microsoft word, Outlook and Internet.

Ability to deal with change and ambiguity.

PREFERRED QUALIFICATIONS:

Bachelor's degree in Nursing.

Minimum of one year experience in utilization review, utilization management, quality review or discharge planning.

Experience in managed care environment.

Experience in working with established criteria to determine medical necessity and appropriateness of care.

Computer experience with word processing, excel spreadsheet management, and other utilization management applications.

DECISION-MAKING:

Functions independently with minimal supervision.

Utilizes clinical judgement

Makes approval and technical denial determinations within scope of practice

Summarizes and sends all potential medical necessity denial determinations to the appropriate Medical Director

Determines when additional resources (Medical Director, Supervisor, etc) need to be consulted

Appropriately informs/refers sensitive or complex cases to Supervisor/Manager.