Cvs Health Utilization Management Jobs in Nebraska

GENERAL SUMMARY:
Responsible for supporting the Utilization Management team by assisting with obtaining documentation/signatures needed for insurance purposes and the explaining the documents to patients in our care. Monitors and records utilization activities of patients under the direction of Utilization Management. Ensures documentation is provided for insurance company requests or determinations. Collaborates in an interdisciplinary manner to optimize patient care, quality reimbursement and regulatory compliance.
PRINCIPAL JOB FUNCTIONS:
1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.
2. *Understands and operationalizes federal regulations regarding Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA and HIPAA; reports safety and customer concerns.
3. *Administers and documents appropriate Medicare Outpatient Observation Notice (MOON), Hospital Issued Notices of Non-Coverage (HINN), Advanced Beneficiary Notices (ABN) and other documents as deemed appropriate.
4. *Adheres to current rules, regulations and policies related to Medicare, Medicaid , and third party payer guidelines.
5. *Interacts in an interdisciplinary manner and serves as a resource regarding patient's insurance guidelines and requirements.
6. *Routes insurance inquiries to the proper persons and departments.
7. *Assists with Utilization Management functions by participating in concurrent and retrospective denials and appeals processes by researching issues surrounding the denial.
8. Assists with admission notification for third party payers.
9. Assists with the process of pre-screens for clinically appropriate admissions and determination for coverage for post-acute services or other transfers.
10. Participates in prioritization and data collection and documentation for time-limited clinical quality or research indictors as requested. Attends staff meetings, mandatory in-services and hospital committee meetings as required.
11. Supports and is involved in the Medical Center's quality initiatives.
12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
13. Participates in meetings, committees and department projects as assigned.
14. Performs other related projects and duties as assigned.
(Essential Job functions are marked with an asterisk "*".
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
1. Knowledge of medical and pharmacological terminology.
2. Knowledge of computer hardware equipment and software applications relevant to work functions.
3. Skill in responding to patient, family and visitor needs with courtesy, consideration, tact and sensitivity.
4. Ability to work independently with minimal supervision.
5. Ability to modify work assignments based on customer requirements.
6. Ability to meet deadlines in a sometimes rapidly changing environment.
7. Ability to communicate effectively both orally and in writing.
8. Ability to maintain strict confidentiality relative to sensitive information.
9. Ability to maintain accurate documentation.
10. Ability to exercise sound judgment, courtesy, tact and professionalism in interacting with others.
11. Ability to communicate and cooperate with all levels of personnel, medical staff and auxiliary and ancillary departments fostering and promoting intro and inter departmental relationships.
12. Ability to work in a fast-paced environment related to changing patient needs including working with patients with acute, chronic and complex disease processes.
13. Ability to maintain regular and punctual attendance.
EDUCATION AND EXPERIENCE:
Licensure or certification in a field of medical or allied health area of study preferred. Minimum two (2) years clinical experience preferred.
PHYSICAL REQUIREMENTS:
(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)
(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.