UM Specialist III-RN Job in Bothell 98011, Washington US
POSITION SUMMARY
Responsible for coordination of daily UM functions in accordance with Molina Healthcare of WA policies and procedures. Coordinates decisions for all services requiring a medical necessity review including: inpatient and outpatient hospital services, diagnostic testing, equipment, home health care, and high cost injectable drugs. Assists Medical Directors with appeal evaluations when needed. Functions as a clinical resource for other non-licensed UM staff. Interacts with the Medical Directors, Molina staff and providers in a professional manner to ensure the delivery of high quality, cost effective healthcare services for Molina members.
Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
REQUIRED SKILLS AND QUALIFICATIONS
Education:
- Bachelor of Science Degree in Nursing preferred.
Experience:
- Two to three years of medical/surgical nursing experience;
- One to two years Utilization Management, Case Management or Home Healthcare experience preferred.
- Computer experience in a Windows environment with ability to learn new information systems and software.
- Familiarity with ICD-9 and CPT coding
Licensure/Certification:
Valid Washington State Registered Nursing license (Must be in good standing.)
PRINCIPLE ACCOUNTABILITIES
- Reviews clinical information provided with request to determine if UM criteria is met. If a medical criterion is met, will authorize service(s) and enter clinical data and authorization services appropriately in QNXT. Maintains familiarity with plan benefits, in order to facilitate interpretation. Demonstrates the ability to apply critical thinking and independent judgment skills. Notifies provider decision regarding request.
- Meets Productivity standards: Process average of 2 authorizations per hour (average/month).
- Requests additional information from providers, per policy, when clinical information does not reflect need for requested services, based on medical criteria. Actively pursues additional sources of information as needed. Uses internal resources appropriately including QNXT, WAmeRx, Spectrum, and K2.
- Reviews clinical information for cases that do not meet criteria. Prepares a detailed, organized analysis of information provided, as well as information requested but not yet obtained, uses template, and escalates requests to the Medical Director for determination. Initiates effective and timely physician interface.
- Processes service requests in compliance with Molina turnaround timeframe policies. Follows department timeframes in all aspects of auth processing.
- Meets department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. Expectation is obtainment of score ≥90% for IRR and average of ≥90% for all quarterly review scores after 90 days of employment.
Essential Job Functions include the following:
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and include the ability to type and operate a personal computer with various software programs, effectively operate standard office equipment, Bend, stoop, crouch, kneel, twist, balance, and work at a desk, Lift and carry up to 25 pounds, and communicate (written and oral) in a clear and professional manner.
Mental/Cognitive Demands: Establish and maintain effective work relationships with co-workers and customers, maintain regular attendance, understand and carry out a variety of oral and written instructions, have knowledge of proper English usage, grammar, punctuation, spelling, and vocabulary, have the ability to learn office principles, practices, and methods, understand filing systems, including numerical, alphabetical, and chronological, learn a variety of procedures, policies, and services of the assigned work unit or program, perform assigned duties with efficiency and accuracy and maintain confidentiality.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
See Job Description
