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Utilization Review Coordinator
Salary Range: $66.43 - $84.81 Hourly
Under the supervision of the Valley Health Plan (VHP) Medical Director and the UM/ QA (Utilization Management/Quality Assurance) Manager, the VHP Utilization Review Coordinator case manages all medical services for the VHP membership as mandated by the regulations and the established policy and procedures. The VHP Utilization Review Coordinator identifies and monitors any quality issues, medical outcomes and all other mandated studies to ensure the provision of quality health care services for the VHP membership.
Performs utilization management tasks for all contracted and non-contracted facilities according to benefits the member is entitled, which includes but is not limited to utilization review, discharge planning, outpatient referrals, after-care and case management;
Reviews cases with Medical Director as per the established medical criteria;
Records and documents outcomes according to the UM/QA policy and procedures;
Performs claim review of services provided for all VHP members, per policy and procedure;
Interprets benefits based on the benefit language outlined in Title 22, Medi-Cal, Medi-Care, and the Commercial Evidence of Coverage;
Reviews medical records for medical necessity and/or potential quality issues;
Collects information required for monitoring for UM or QI projects; ie: HEDIS 3.0, State Reports, focus studies, ER Study, OB Study, etc;
Serves as staff support to the Utilization Management Committee and the Quality Improvement Committee related to medical outcomes;
Assists in implementing any changes recommended by the Utilization Management and Quality Improvement Committees;
Performs network facility and UM departmental audits according to regulations;
Participates in job related meetings;
Interfaces with all VHP departments in management of members and provider network;
Acts as a resource to all internal and external customers related to medical services to members;
Performs other related duties as required by VHP.
Possession of a current California Registered Nurse license, a minimum of four years nursing experience in an acute care setting, and one year experience in utilization management, case management or equivalent in a managed care environment. A Bachelor's Degree in Nursing or Bachelor's/Master's Degree in Health Care Management or related degree from an accredited college or university may be considered in place of up to two years experience in a health maintenance organization.
Federal and state health care laws, regulations and standards relating to quality of care, standards of practice for professional staff, and the operation of hospitals, clinics, health maintenance organizations and providers of Medi-Cal, Medi-Care, and Commercial services in California;
Computer management systems and data file management;
Billing/reimbursement practices in the health care industry;
Clinical nursing practice and levels of care and treatment in the health care system;
Cultures of the diverse population in Santa Clara County and how
members of those cultures relate to the health care industry.
Audit and inspection of requirements of an HMO by regulatory agencies.
Communicate effectively both orally and in writing;
Ability to assess, identify, implement process, evaluate, and show medical outcomes;
Maintain effective data collection, recording, and reporting systems;
Evaluate and interpret data and statistics;
Analyze problems and formulate and implement effective solutions.
Work effectively with professional staff, subordinates, vendors, customers/patients and others in a courteous and professional manner;
Interpret and maintain knowledge of health care laws, regulations, standards, policy and procedures;
Work independently in setting priorities;
Maintain positive work relationships with the various network providers.
Updated: 3/21/2019 11:17:24 AM