Utilization Management Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 55,000 - 85,000; Full time

Job summary

MCS Puerto Rico is seeking a qualified registered nurse to conduct prospective reviews and determine appropriate levels of care based on clinical guidelines and medical necessity.

The role requires a Bachelor’s degree in Nursing Sciences, at least three years of healthcare experience, and an active Nurse & Association Nursing Professionals of Puerto Rico license. Fluency in Spanish and English at an intermediate level is expected in this position.

Qualifications

• Bachelor’s degree in Nursing Sciences.
• At least three (3) years of experience in a healthcare environment.
• A valid Nurse & Association Nursing Professionals of Puerto Rico License and Registration is required.

Responsibilities

• Offers guidance on the precertification process to clients and providers.
• Performs organizational and benefit determinations per regulatory requirements and timelines.
• Conducts prospective reviews of diagnostic studies, procedures, and equipment to assess medical necessity.
• Ensures client care aligns with service levels, using clinical guidelines to assess medical necessity.
• Obtains and evaluates required clinical information and communicates determinations to stakeholders.

Skills

Nursing

Education

Bachelor’s degree in Nursing Sciences

Job description

GENERAL DESCRIPTION:

Conducts prospective reviews (preauthorization’s) of items or services provided to beneficiaries using the Clinical Guidelines criteria for assessing medical necessity. Determines the appropriate level of care according to the severity of the subscriber’s condition. Ensures the appropriate use of healthcare resources and guarantees the well-being and quality of services provided to our subscribers through appropriate processes.

Regular
Exempt

GENERAL DESCRIPTION:

Conducts prospective reviews (preauthorization’s) of items or services provided to beneficiaries using the Clinical Guidelines criteria for assessing medical necessity. Determines the appropriate level of care according to the severity of the subscriber’s condition. Ensures the appropriate use of healthcare resources and guarantees the well-being and quality of services provided to our subscribers through appropriate processes.

ESSENTIAL FUNCTIONS:

• Offers guidance on the precertification process to our clients and providers.
• Performs the Organizational and Benefit Determinations in compliance with regulatory requirements and established timelines for each line of business, prioritizing cases based on urgency in accordance with the Operational Guidelines, Policies and Procedures.
• Performs prospective review (preauthorization’s) of diagnostic studies, invasive and non-invasive procedures, durable medical equipment, home care, skill nursing facility, inpatient rehabilitation facility, comprehensive outpatient rehabilitation facility and non-emergent transportation
• Ensures clients' care according to the service level, applying clinical judgement and using InterQual, Medicare, and Organizational Clinical Guidelines to assess medical necessity.
• Obtains and evaluates required clinical information, refers cases not meeting clinical criteria to the Medical Advisor, and communicates determinations to clients, providers, and appropriate stakeholders according to established standards.
• Documents actions taken in the electronic clinical record.
• Identifies members requiring additional support and coordinates referrals to appropriate clinical, care management, transition of care, community, and provider resources to ensure continuity of care.
• Acknowledge when to request assistance or direction using communication channels.
• Maintains professional and respectful communication with clients, families, providers, and colleagues, fostering teamwork and actively participating in cross-functional meetings and quality improvement initiatives.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and experience: Bachelor’s degree in Nursing Sciences. At least three (3) years of experience in a healthcare environment.

Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico License and Registration is required.

Other: N/A

Languages:

Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

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