Especialista De Manejo De Utilizacion

Especialista de Manejo de Utilizacion




GENERAL DESCRIPTION

Conducts prospective reviews (preauthorization's) of items or services provided to MCS beneficiaries using the Clinical Guidelines criteria for assessing medical necessity. Determines the appropriate level of care according to the severity of the subscriber's condition. Ensures the appropriate use of healthcare resources and guarantees the well-being and quality of services provided to our subscribers through appropriate processes.

ESSENTIAL FUNCTIONS

* Performs the Organizational and Benefit Determinations process according to the established requirements and timelines of the regulatory agencies for each line of business, in accordance with the Operational Guidelines, Policies, and Procedures.
* Offers guidance on the precertification process to our clients and providers.
* Prioritizes, recognizes, and processes cases by the level of urgency efficiently within the timelines established on the TruCare platform.
* Performs prospective review (preauthorization's) of diagnostic studies, invasive and non-invasive procedures, durable medical equipment, home care, skill nursing facility, inpatient rehabilitation facility, comprehensive outpatient rehabilitation facility and non-emergent transportation.
* Manages clients' care according to the service level, applying sound clinical judgment and established processes.
* Utilizes InterQual, Medicare, and Organizational Clinical Guidelines and manuals during the prospective review process to determine the medical necessity of the requested service.
* Communicates and collects clinical data necessary for the evaluation of the claim.
* Documents actions taken in the electronic clinical record.
* Consults and refers cases that do not meet clinical criteria to Medical Advisor.
* Communicates to a client, provider, or appropriate designer, the outcome of the claim following established standards and procedures.
* Identifies and refers to appropriate clinical unit high utilizers or those with potential diagnoses, ensuring continuity of care.
* Acknowledges when to request assistance or direction using communication channels.
* Identifies and appropriately directs referrals to providers for payment arrangements, community outreach, transition of care management and care management.
* Uses appropriate and understandable language during the management of client and provider calls.
* Promotes a teamwork environment aligned with corporate mission, vision, and values.
* Maintains a cordial relationship with clients, family members, and providers.
* Participates and collaborates in cross-functional meetings and departmental quality initiatives as needed.
* Complies fully and consistently with company standards, policies, procedures, and local and federal laws applicable to our industry, business, code of conduct, and employment practices.
* May perform other duties and responsibilities as assigned, in accordance with the education and experience requirements contained in this document.

MINIMUM QUALIFICATIONS

Education and experience: Bachelor's degree in Nursing Sciences. At least three (3) years of experience in a healthcare environment.

Certifications / Licenses: Nurse & Association Nursing Professionals of Puerto Rico

Other: N/A

Languages:
Spanish – Intermediate (writing, reading, comprehension, and conversation)
English – Intermediate (writing, reading, comprehension, and conversation)




"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"