Utilization Management Specialist
Group 1001

Group 1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001's culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets - our employees.

Company Overview:

Clear Spring Health is part of Group One Thousand One ("Group1001"), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina and offers Medicare Prescription Drug Plans in 42 states plus DC.

Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals. All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.

Job Summary:

Under the direction of the Utilization Management Team Lead, the Utilization Management Specialist is responsible for performing all utilization management activities to include reviewing, screening, processing and authorizing admissions, services, and Part B drugs requests from providers, members, and members' representatives.

Main Accountabilities:

• Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, durable medical equipment (DME), Part B drugs, and outpatient and home health services.
  
• Monitors level and quality of care of services being provided and approved.
  
• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
  
• In conjunction with, and under the supervision of the Utilization Management Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans and available covered services including identifying alternative levels of care that may be covered.
  
• Monitors the Utilization Management system to assure compliance with turnaround time frames.
  
• Addresses care issues with Utilization Management Team Lead and Medical Director when appropriate.
  
• Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members.
  
• Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly.
  
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members' representatives, facilities, requestors, and service providers.
  
• Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames. Reviews all NON-certification files for correct documentation.
  
• Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department.
  
• Participates in the ICT meetings for the SNP membership.
  
• Performs other related activities as assigned.
  

• Licensed Registered Nurse
  
• Experience in the application of Milliman criteria or other evidence-based medical criteria.
  
• 2 - 4 years utilization review and/or managed care experience preferred
  
• Knowledge of medical problems encountered with Seniors.
  
• Working knowledge of Medicare Advantage Plans.
  
• Strong computer skills - Microsoft Office Suite
  
• Strong communication and interpersonal skills
  
• Ability to effectively present medical information one-on-one