Utilization Review Coordinator

🔥 0 minutes ago

🦞 Maine, New Hampshire, +1 more states – Remote

🦞 Maine – Remote 🗻 New Hampshire – Remote 🍂 Massachusetts – Remote

💵 $80k - $90k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Health Plans, Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1981

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Health Plans, Inc. (HPI) is a leading national third-party administrator (TPA) that specializes in self-funding solutions for employers and benefits brokers. HPI offers innovative health plan designs, including Consumer-Driven Health Plans (CDHP) and reference-based pricing, tailored to meet the unique needs of individual markets. With a commitment to providing advanced analytics and customized solutions, HPI aims to put employers in control of their healthcare costs while enhancing the member experience.

📋 Description

• Review clinical information to determine medical necessity, appropriate level of care, and length of stay using standardized clinical criteria • Render positive determinations for cases meeting criteria and refer other cases for physician peer review • Gather relevant clinical information from appropriate health care providers • Confirm medical necessity for selected procedures and services • Conduct utilization management for level of care and length of stay • Consult with Peer Reviewers when criteria do not support a positive determination or peer consultation is needed • Screen cases promptly to identify case-management needs and make appropriate referrals • Follow up on outstanding utilization-management issues and inquiries • Collaborate with providers to identify discharge needs and facilitate timely discharge to the appropriate level of care • Communicate with providers and other health care professionals about the Utilization Management process • Maintain case documentation according to policy and procedure • Collaborate with the Manager on professional growth • Apply standardized criteria consistently and maintain satisfactory quality audit scores • Manage work time and caseload efficiently • Adhere to HIPAA policies and procedures

🎯 Requirements

• Minimum of three years of experience in an acute care clinical setting • Active, current and unrestricted professional licensure as an RN or LPN in Massachusetts, Maine, New Hampshire, or the state of residency • Proficient in Microsoft Office, including Word, Excel, Outlook, and PowerPoint • Knowledge of standardized clinical criteria for medical-necessity and utilization-management reviews • Ability to perform utilization management for level of care and length of stay • Ability to follow HIPAA policies and procedures • Ability to maintain documentation according to policy and procedure • Ability to manage work time and caseload efficiently

🏖️ Benefits

• Medical, Dental and Vision and Prescription Drug Coverage • Fitness Reimbursement Benefit • Employee Assistance Program • Flexible Spending Account & Health Savings Account • 401(k) • Quarterly Bonuses • Generous Paid-Time Off • Volunteering Opportunities • Educational Assistance • Professional Development Opportunities • Smart casual dress code • Ergonomic desks • Onsite café, office-park trails, and campus gyms when at the Westborough headquarters