Position Description This clinical position is part of the Utilization Management department and is responsible for processing prior authorization and/or medical claims review (post-service) requests through clinical review and the application of approved medical necessity criteria. Collaboration within and across departments and operating professionally and efficiently within the framework of established policies and procedures is essential. The focus of this role is review of elective inpatient and select outpatient services. Responsibilities and Qualifications Duties and Responsibilities:

• Processes prior authorization and/or medical claims review (post-service) cases through review of the submitted request and applicable clinical records and applying approved medical necessity criteria to determine medical necessity and appropriateness of the service or item requested.
• Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, the CHIP handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or American Society of Addiction Medicine (ASAM) guidelines to these requests as applicable to the member’s product.
• Performs UM case reviews within the framework of applicable regulatory requirements and established policies and procedures of Capital’s UM department. Complies with both internal policies and all regulatory requirements regarding members confidentiality.
• Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination.
• May participate on occasion in clinical rounds to discuss members as needed and requested. Identifies and refers members with complex needs to the appropriate population health and/or care management program.
• Identifies and refers members with Potential Quality Issues (PQIs) through established processes to the applicable department for further review and investigation.
• Offers suggestions for improvement in departmental processes and identifies opportunities for learning and education.
• Attends and participates in company and departmental meetings and training sessions as required and requested.
• Practices within the scope of clinical license and/or certification.

Skills:

• Demonstrated ability to critically think through processes to make clinically appropriate decisions and problem solve.
• Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments.
• Demonstrated ability to work independently and as part of a team.
• Demonstrated ability to interact with other departments actively and proactively, as needed, to advise, educate, and/or direct members to other clinical programs and services.
• Demonstrates openness, flexibility, problem solving, patience, and tact when interacting with members, family, providers, and peers.
• Demonstrated ability to communicate in a concise and clear manner in both written and oral communications.

Knowledge:

• Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications.
• Knowledge of medical coding guidelines, including ICD-10-CD, CPT, and HCPCS codes.
• Working knowledge of National Committee for Quality Assurance (NCQA), CMS, and other health plan UM regulations.
• Knowledge of managed care principles and emerging health treatment modalities.

Experience:

• A minimum 3 years’ relevant clinical experience required.
• 1year prior authorization and/or medical claims review experience required
• 1 year UM experience in managed care preferred.

Education and Certifications:

• Must have active current Licensed Practical Nurse (LPN) or Registered Nurse (RN) in the state of Pennsylvania.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.