Req# 28147 Aultman Health Foundation, CANTON, OH AULTCARE ADMINISTRATION Aultman Health Foundation Full Time, Day Shift, 8-4:30 PURPOSE OF POSITION: The primary purpose of the Utilization Review RN Care Manager is to utilize medical necessity criteria to make/support decisions regarding the appropriateness of requested procedures, treatments, therapies, and diagnostic procedures for pre-authorization, concurrent review, and retrospective review of inpatient and outpatient services. The Utilization Review RN Care Manager applies medical necessity criteria to support a clinical rationale for care decisions, promote clinical quality, and the cost-effective use of medical resources. Collaborates with Care Coordination staff members, Physicians, and Financial team staff members to review services requested, and provide feedback to the ordering provider if desired services do not meet the medical necessity criteria. Actively participates in on-going efforts to identify and educate providers regarding evidence-based and cost-effective alternatives for care delivery. RESPONSIBILITIES & EXPECTATIONS: Gathers relevant information accurately and systematically. Performs reviews thoroughly with high attention to detail, including incomplete requests that have been previously managed by other staff. Reviews documentation of member needs and processes or obtains authorizations based on clinical criteria, payer contracts and custom plan language including narrowed and tiered networks. Applies Utilization Management policies that result in cost-efficient utilization of services Identifies medical necessity criteria discrepancies and forwards to physician reviewers in a timely manner to receive certification determination and/or physician-to-physician communication. Communicates with members and providers telephonically about network capabilities and how the member's needs can be most appropriately met. Advocates for member to receive timely care at most appropriate place of service Generates approval and denial letters as directed by the Director, Supervisor or Medical Director, appropriately incorporating the specific clinical criteria and plan language utilized to arrive at determination. Learn and utilize tools and processes to perform and properly track all utilization reviews, as well as refer members to further care engagement and stop loss when needed (i.e. catastrophic illness) to ensure that members are receiving appropriate medically necessary services covered by the plan. Other duties as assigned (i.e. employer-group specific reporting, assistance with administrative case audits, perform audit data validation, etc.). Anticipates and follows through with both internal and external customer requests to their satisfaction. Meets departmental and regulatory turnaround time requirements. Maintains confidentiality of enrollee and employer information at all times. Complies with policies, procedures and code of conduct, Ohio Nurse Practice Act, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other governing and accrediting bodies. Seeks supervisory guidance/approval as appropriate. Customer Service/Satisfaction Anticipate and follow through with both internal and external customer request to their satisfaction. Seek assistance of others and other departments when needed. Maintain cooperative approach in dealing with co-workers, creating productive working relationships. Be flexible and willing to change. Keep lines of communication open. Express ideas and information verbally and in writing using appropriate grammar, word usage and organization of ideas clearly and concisely. Deal with a diversity of people in a broad range of circumstances. Communicate with customers in a professional manner and maintain positive contact wit