Non Clinical Utilization Review Jobs in Puerto Rico

Position Summary:

The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.

Essential Functions:

1. Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence.
2. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed.
3. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process.
4. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process.
5. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines.
6. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information.
7. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements.
8. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.
9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications.
10. In addition, all other duties assigned by the manager and/or supervisor.

Education:

• Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing.
• Current, unrestricted clinical license(s) to practice in Puerto Rico territory.

Experience:

Knowledge:

• Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
• Strong knowledge in behavior principles, chronic illnesses, and disease management.
• Strong telephonic assessment and customer service skills.
• Knowledge in community-based resources.
• Knowledge in clinical assessment and crisis intervention.
• Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.