Insurance Utilization Reviewer Jobs in Alabama (NOW HIRING)

BASIC FUNCTION
Administer Utilization Review activities including:

1. Prospective, concurrent, retrospective and appeals reviews for inpatient admissions, focused procedure reviews, Home Health, and Hospice reviews as indicated for dedicated group to assure compliance with group requirements
2. Perform and/or coordinate case management activities (includes catastrophic and non-catastrophic cases) for the group
3. Monitor and evaluate group specific data for intervention and reporting
4. Communicate with marketing and group contacts to assure compliance and meet group specific needs

WORKFLOW
For Utilization Review, work is received via telephone, facsimile, Internet, or mail, Case management functions are initiated through referrals from hospitals, physicians, groups, agencies, Blue Cross and Blue Shield internal sources, and/or patient or family members. The incumbent performs reviews of procedures and diagnoses for medical necessity of place of treatment in order to determine benefit coverage for admissions or continued stays, and to determine the appropriate level of care. The incumbent also analyzes the patient's contract benefit structure during the review. During the Case Management process the care coordinator reviews the physician's plan of treatment in order to evaluate the patient's status and needs, and may do an on-site evaluation. The incumbent develops a plan of treatment that maximizes benefit coverage and quality of care. The plan may be based upon regular benefits or alternative benefits. The plan of care includes cost projections and an evaluation of the plan with the physician, patient and family, and the group. The plan of care may require contractual arrangements to be set up with providers, patient and family. At the request of providers/subscribers, the incumbent reviews non-certified claims on appeal and makes determinations with the assistance of a peer clinical reviewer or medical director, if necessary. If a problem has not been addressed by guidelines, the incumbent researches and recommends options. Periodically, cases are reviewed and assessed, and treatment plans are revised or improved as necessary. The incumbent may provide periodic reports to the Group.
KNOWLEDGE
The incumbent must have a thorough understanding of medical services, which is based on clinical experience. The incumbent must know claims payment guidelines, billing guidelines, laws and contracts that govern the health insurance programs administered by the corporation. As a representative of the corporation, the incumbent must apply acquired job knowledge, work to defuse the situations, and apply problem solving skills. Examples may include performing reviews of patients' care in hospitals or meeting with the hospital staff, providers, and legal representatives. Accurate documentation including personal and telephone contacts must be kept in the case file.
The incumbent must have the ability to meet and effectively communicate with all levels of management, possess mature judgment, and the ability to resolve most problems independently.
The incumbent must maintain current knowledge of UM review principles applicable to the job.
The incumbent adheres to the confidentiality and conflict of interest policies as set forth by the corporation.
Active license as a Registered Nurse (RN).
Bachelor degree or upon hire commit to actively pursue a degree
Three years clinical experience in medical/surgical health care fields.
Currently licensed by the state of Alabama as a RN or, upon hire, agree to actively pursue Alabama license
Upon hire, the incumbent will attest to practice within the scope of their licensure; and each year thereafter will confirm that they do so by signing an attestation agreement. The incumbent will notify management of any issues that will impact, change or threaten this agreement.
Effective verbal and written communication skills.
Ability to analyze a clinical situation and make informed decisions in an autonomous setting.
Must be willing to work a flexible schedule in order to provide telephone coverage.
Acquire and maintain specific specialty certifications applicable to the job.
The incumbent must notify management immediately of any changes to licensure/certification status.
THINKING REQUIREMENTS
The incumbent must be an independent thinker and able to work closely via personal, written or oral communication with representatives of the group, patient and family, and professionals inside and outside the Corporation. These groups include the provider financial and medical representatives, customer representatives, subscribers, and Blue Cross and Blue Shield representatives. In fulfilling these responsibilities, the incumbent must be able to organize travel, which may include overnight travel.
INTERFACES AND INTERPERSONAL SKILLS
The incumbent has telephone and personal contact with groups, providers and their office representatives, patients and their family members, internal departments involved with medical care, marketing, claims processing, BCBS Medical Directors and legal staff. This communication may be one-to-one or involve presentation to a large audience. The incumbent must be able to establish effective communication to resolve problems. In order to gain acceptance for the plan, the incumbent must be able to effectively articulate alternative plans of treatment and benefits to the group, physicians, and the patient and family members.
AUTHORITY AND DECISION MAKING
The incumbent reviews cases for medical necessity of inpatient admissions or other services. Must be able to do appeal reviews of non-certified PAC claims. Cases are submitted to peer clinical reviews when medical necessity guidelines are not met. Resolves problems for subscribers, groups, and providers.
The incumbent utilizes analysis and decision-making skills in order to evaluate benefit structures and propose effective plans of treatment. Negotiation and communication skills are necessary for discussing costs and flexible benefits with providers, group representatives, and patients.
The incumbent may be responsible for participation in revisions/developments of the Blue Cross and Blue Shield of Alabama medical necessity guidelines. Decisions are based on development or revision of existing guidelines, literature review and current trends in healthcare.
The incumbent operates in an autonomous environment, demonstrates independent thinking and accountability for decisions.
PRINCIPAL ACCOUNTABILITIES

• Activity: Perform utilization reviews to determine services provided to members (prospective, concurrent, retrospective, and appeal reviews).
  End Result: To assure that care is medically appropriate

• Activity: Perform an assessment of a patient's medical status and needs in light of benefits structures, available resources, and other issues in order to propose a flexible and quality plan of treatment.
  End Result: Promote acceptance of an alternative plan, including making contractual arrangements to carry out the plan

• Activity: Provide on-going monitoring and review of cases. Make revisions to plans, problems and goals as necessary.
  End Result: To assure that the current plan is effective. To identify problems or obstacles that may be resolved through intervention

• Activity: Manage cases that involve both catastrophic and non-catastrophic type illnesses.
  End Result: To provide quality service across a continuum of care that addresses the needs of each individual

• Activity: Provide periodic reports to the group on patient progress and benefit utilization.
  End Result: To apprise groups of costs that are attributable to the members

• Activity: Respond to telephone or written requests for information from subscribers, providers, and group representatives (within the scope of Privacy Guidelines).
  End Result: To demonstrate our Customer First and Caring Company philosophy

• Activity: Perform special projects as requested.
  End Result: To promote achievement of divisional goals

• Activity: Compile reports reflecting activities.
  End Result: To provide management with data for workflow planning and problem trend identification

• Activity: Prepare reports for presentations to groups (may be in conjunction with Marketing). Prepares dialogue and support materials for groups, agencies, or providers that focus on education program components.
  End Result: To keep groups and/or Marketing apprised of trends in the healthcare delivery system that impact the group