1. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
2. Effectively and efficiently review prior authorizations and retrospective authorizations, providing updated criteria and necessity, utilizing the appropriate tools and reviewing diagnostics that is and consistent with the members' eligibility, benefits and contract:
a. Conducts initial medical necessity clinical screening; including determining type and level of request and units/number of services requested is appropriate.
b. Conducts initial medical necessity review of out of network requests for services requested outside of the client health plan network.
c. Notifies ordering physician or rendering service provider office for any changes and modifications to authorizations as well as determination made, as needed.
d. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review of pharmacist reviewer, physician reviewer, and/or medical director.
e. Consult with healthcare providers, physician reviewers, pharmacy reviewers, and Medical Directors to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
f. Serve as front line support to the physician reviewers and medical directors in securing criteria and medical history of requested referrals, especially high cost referrals.
g. Work in collaboration with the Medical Director and Care Coordination teams to thoroughly review member referral history and anticipated needs in an effort to avoid referral leakage and admission.
h. Identifying the appropriate settings in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for needed clinical services and care.
i. Works with medical directors in interpreting appropriateness of care and accurate claims payment.
j. Documents the results of the initial clinical review and determination in the organization's referral management system.
k. Creates and prints denial letters with specific reason written in easily understandable language and meets CMS requirements and NCQA UM Elements.
I. Ensure compliance with state, federal, DMHC, and CMS regulations; as well as
turnaround time compliance in processing authorization accordingly.
3. Investigating, processing, and assist with the resolution of provider grievances and appeals in accordance
with contractual requirements and corporate policy, duties may include but not limited to:
a. Conducts investigations and reviews of member and provider grievance and appeals.
b. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
c. Extrapolates and summarizes medical information for medical director, consultants and other external review.
d. Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
e. Ensures that appeals and grievances are resolved timely to meet regulatory time frames.
f. Documents and logs appeal/grievance information on relevant tracking systems and referral management systems.
g. Generates written correspondence to providers, members, and regulatory entities.
h. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
4. Collaboration with clinical teams and practices to ensure synchronization of sub-areas' operations to reach organizational and departmental goals, this include but not limited to:
a. Collaborate with inpatient and outpatient care management teams to review weekly/monthly admissions, as well as meet monthly to discuss high cost members with readmission(s) for their assigned clinical practices in order to assess and develop a care plan in collaboration with referring physicians; and other healthcare practitioner.
b. Review and report/present their assessment, interventions, evaluations to the respective care teams, clinical practices, providers, and UM committee of identified high cost patient and/or services, particularly those with facility components.
c. Applies clinical knowledge to work with facilities and providers for care coordination or appropriate referral to outpatient care management.
d. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
e. Interaction with clinical providers and at minimum bi-monthly visits to PCP and Specialist offices unless visit is warranted at earlier to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
f. Network management/development: develop tools and training curricula to educate providers and their staff how to meet expectations and goals as prescribed in their contract.
g. Educate internal and external customers including clinical practices about plan benefits, medical management/UM, and definitions of medical appropriateness/medical necessity.
h. Recommends treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines.
i. Responsible for working collaboratively with the operations, care coordination department, and medical director to ensure network growth and development initiatives are being met and operating within budgets.
j. Expert in analysis of data and acts as the change agent in the continuous optimization and maintenance of successfully integrated programs and processes established to meet the operational goals of the organization.
k. Ensure accurate and timely data reporting requirements are being met including eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day's utilization, encounter data and audit compliance.
I. Represents as the UM/Medical Management liaison to Clinical Optimization Meetings and/or Utilization Management Committee, when assigned.
5. Identify possible adverse selection cases for new members with high cost diagnosis and/or comorbidities.
6. Maintaining and updating the appropriate databases and department tools with current information.
7. Ensure contract compliance and adherence to DMHC, OHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
8. Oversight of database maintenance and accuracy through use of audits.
9. Must obtain an overall score of at least 90% with internal case review file audits.
10. Assist management with any special projects, as assigned.
11. Meet department performance standards and metrics.
12. Know and follow the Employee Handbook policies and procedures.
13. Maintain patient and provider specific confidentiality so that HIPAA compliance is observed at all times.
14. Give directions in regards to Medical Management Coordinator function and activities to assist them (nurses) of their daily production and performance in order to complete all assigned work by the end of business day.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.