UM Report Reviewer

Reports to the Senior Director of Clinical Services. Needs someone with strong knowledge of the role of the Utilization Management department in a health plan. Responsible for reviewing and analyzing all Utilization Management reports; CMS ODAG and Part C as an example. Monitors the integrity of data being reported. Interacts with clients and internal staff to ensure that reports are submitted timely. Maintains log of all reporting requirements, tracks and communicates deadlines to internal staff members and management team. Produces monthly and quarterly Power Point presentations with data interpretation to Health Plan clients and HN1 entities. Updates management on any note-worthy trends. Maintains and updates UM policies and procedures to match federal, state and NCQA requirements. Responsible for completion and submission of UM Health Plan Audit requests. Assists with documentation required to obtain state licenses by the company as a Utilization Review Agent.

Essential Functions & Responsibilities

  • Knowledge of the prior authorization process of the Utilization Management department.
  • Aware of all Service Level Agreements required by each Health Plan, State and Federal agency, such as turn-around times (TAT).
  • Responsible for reviewing and approving all UM reports due to the health plans. This includes:
    • ODAG, Part C CMS reports
    • Service Authorization Performance Outcome report for state of Florida
    • Dashboard and KPI reports for the Health Plans
    • Data validation of all UM reports
    • Ticket creation related to reporting errors
    • Tracking those tickets and resolutions
    • Keeping management in the loop when there are critical problems and potential for missing deadlines
  • Performing ad-hoc reviews of reports for prevention of errors, TAT related or reporting related
  • Analyzing the data to note any concerning trends
  • Responsible for creating the UM PowerPoint Presentations that are presented to various Health Plans during JOC meeting, and HN1 internal Quarterly meetings. Ensuring the data aligns with what is reported on the UM Dashboard, monthly and quarterly to the Health Plans.
  • Creating and/or running ad-hoc reports for various data requests by the executive team
  • Prepares Health Plan annual audit requests, and any ad hoc audit requests, at the direction of management
    • Gathers all policies related to the request
    • Prepares cases for Health Plan review
    • Analyzes and reports to management any areas that put the department at risk
  • Maintain UM policy and procedures. Reviews each policy annually. Ensures each policy is up-to-date with the most recent local, state, federal, or NCQA requirements. Updates the policies on an as needed basis whenever there are any changes, or direction given by a Health Plan.
  • Assist with obtaining state licenses for the company as a Utilization Review Agent (URA):
    • Review requirements
    • Fills out UM application
    • Provides UM documents required
    • Tracks status of the application
    • Tracks other states that require a URA License.
  • High level of proficiency with Microsoft Office Suite, including strong Excel skills in order to run, review and analyze the reports
  • Strong documentation skills for maintaining logs for tracking and producing monthly/quarterly reports.
  • Ability to investigate internal & external queries with regards to client requests
  • Ability to build strong relationships with internal colleagues and external client contacts
  • Ability to work on multiple projects with accuracy and efficiency, while keeping to deadlines.
  • Strong attention to detail balanced with the ability to think strategically.
  • Strong analytical, problem-solving and organizational skills.
  • Ensures integrity of data entered into company systems and/or databases
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Required Education and Experience

  • Required: Minimum 2 years health care industry experience.
  • Required: Intermediate experience working with excel reports, pivot tables, and filters
  • Required: Intermediate Experience working with Power Point
  • Required: Experience with Health Plan/Governmental agency audits such as CMS
  • Highly recommended: Experience with Utilization Management prior authorization review process from initial review to approval or denial.
  • Highly recommended: Experience with CMS policies especially Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance
  • Highly recommended: Experience with CMS reporting requirements including Part C and ODAG reports

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