Utilization Review Assistant Jobs in Reno, NV (NOW HIRING)

Position Purpose

The Medical Director is one of the health plan's clinical leaders and is responsible for helping to develop and implement health plan policies on patient care facilitation, serving as a medical liaison with contracted physicians, assisting in the discussion surrounding Quality Management, Case Management, and Utilization Review programs. The Medical Director also has clinical oversight responsibilities for the plan products including the Medicare Advantage and ACA plans’ Risk Adjustment Revenue enhancement program as it pertains to Behavioral Health. The Medical Director will also be involved in the direction of the Renown Health System population health strategy in its overlap with the health plan duties and initiatives. The Medical Director is a member of the Hometown Health Leadership team and participates in the strategy for the plan including new and current programs and product implementation and configuration related to Behavioral Health.

Nature and Scope

Function as the Behavioral Health Medical Director of Hometown Health and related entities. Assist in developing Hometown Health Board-approved policies relating to overall patient care programs. Serve as a clinical leader for the plan’s Quality Management and Utilization Management programs related to Behavioral Health. Said duties shall include, but not be limited to, the following:

• Attend the Behavioral Health Interdisciplinary Team meetings.

• Provide guidance concerning the management of the behavioral health inpatients with direction as to appropriateness of the level of care and treatment plan. This may require pre or post meeting medical record review.

• Provide guidance for clinical operational aspects of the program.

• Has responsibilities for oversight of clinical decision-making aspects of the program. Will have periodic consultation with practitioners in the field.

• Help monitor the effective implementation of the Plan’s quality Management programs.

• In conjunction with the Quality Management Committee, discuss quality of care standards, both in the inpatient and ambulatory sectors.

• Assist the utilization management team with medical necessity determinations surrounding behavioral health

• Ensure the plan is MHPEA compliant

• Provide appropriate support of problems identified through the plan’s Quality Management program.

Provide direction and support for the clinical utilization review process which includes:

• Support of the Utilization Review Programs of Hometown Health.

• Help foster utilization policies and procedures.

• Communicate utilization issues with providers as needed.

• Enter behavioral health authorizations into the Epic EMR.

Additional Responsibilities include:

• Assist in management for the Medicare Risk Adjustment, chronic condition coding and revenue enhancement program.

• Assist in the evaluation of and contracting with health care providers and suppliers.

• Assist the plan in analyzing its Behavioral Health practice needs.

• Help support pharmacy programs of the plan related to Behavioral Health.

• Peer to peer discussions with other behavioral health specialists as to the care of members and medical necessity

This position does not provide direct patient care, but only to the extent patients are discussed as identified above.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications
Requirements - Required and/or Preferred

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English. Medical Degree (MD or DO) from Accredited University

Experience:

Minimum of two (2) years post graduate clinical practice experience in direct patient care. Experience in the managed care environment which includes significant involvement with utilization and quality management is desired but not necessary for the right candidate.

License(s):

Must possess and maintain a current and valid State of Nevada Doctor of Medicine (MD) or Doctor of Osteopathic (DO) medicine license.

Ability to obtain and maintain a valid State of Nevada driver's license and ability to pass Renown Health's Department of Motor Vehicle Report criteria.

Certification(s):

Board certified and verified by American Board of Medical Specialists.

Computer / Typing:

Must be proficient in Microsoft Office Suite, including Outlook, PowerPoint, Excel, Teams, and Word and have the ability to use the computer for online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.

Ability to credential through Renown’s Medical Staff and/or payor credentialing, as applicable.