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Facilitates the utilization of resources to meet patient outcomes and contribute to Facility (AMC), New York State and National Quality data metrics. Performs review and triage of incoming test results, patient requests and pharmacy renewals; facilitates call-backs to patients as necessary.
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Ensure the accuracy and appropriateness of all prescriptions filled by completing Drug Utilization Review and Final Quality Assurance, applicable to state and federal Board of Pharmacy regulations.
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Oversee and make decisions related to performance of fabrication shop work and review jobsite needs with project staff for logistics, organization, plant layout, equipment, quality control, and workforce utilization.
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The Utilization Review (UR) Nurse is responsible for the clinical review and documentation for services requiring prior authorization. Minimum of two (2) years Utilization Management experience is preferred.
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Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.
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This job captures all inbound requests for utilization review from providers and pharmacies. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the patient, and then creates the case (data entry) in Highmark's utilization management system for clinical review.
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Review of identified high-cost admissions and extended stays and inpatient readmissions. Demonstrated ability to review health care delivery against established criteria. This includes approval determinations and appropriate exceptions, coordinating with Medical Directors on denials, completing inpatient level of care reviews, post-acute care initial and concurrent reviews for acute and subacute rehabilitation, transportation and DME requests.
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The ROSA Zone Program Development Director builds successful programs by aligning with key stakeholders including surgeons, staff , executives and local implant teams to drive system utilization with the ROSA Robotic Knee Platform.
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Build profitable business and script growth through recommended clinical programs including appropriate immunization and when available MTM (Medication Therapy Management), DCS (Diabetes Care Specialist), and all ongoing other programs as identified.
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These responsibilities may include utilization review, pharmacy oversight and care coordination. Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines.
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Experience in skilled nursing facilities, clinical reimbursement, concurrent review and/or utilization management is desirable. Review clinical documentation to define expectations, criteria, and variables that will impact the care plan and outcomes.
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While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies.
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Utilization and application of scientific knowledge and techniques for data review activities supporting potency and bioassays. Review of logbook and lab notebooks for accuracy and completion.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post acute services such as inpatient rehabilitation.
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As a Medical Director you will focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews and reviews of claim determinations. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.
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utilization review jobs in Latham, NY
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