Job Details

Directs the activities of the UM staff, with direct supervision by the medical director regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care and other clinical and medical management programs Aids, approves and intervenes, as needed, to determine medical necessity, appropriateness and extended length-of-stay decisions Assists inpatient care manager in UM of members with complex medical care involving numerous providers or frequent intervention Participates in State- or plan-required audits and complies with all reporting requirements by area of responsibility Oversees reporting and monitors potential high-cost cases, readmissions, UM statistics to include admits per thousand, bed days per thousand, length-of-stay and readmissions per thousand within 30 days of discharge Develops and implements action plans for improvement, as needed Liaisons with the national UM team...Manager, Management, Medical Director, Remote, Health, Healthcare