RepuCare
  • - Managed Care
  • Indianapolis, IN, USA
  • Full Time

 

RepuCare is a woman-owned business (certified WBE) and a leading provider of medical management solutions for state, federal and corporate healthcare programs. We are partnered with a large healthcare company to provide medical management staff to support their state-sponsored Medicaid programs. RepuCare provides a comprehensive benefits program including medical, PTO and 401K for full-time employees.
 

SUMMARY: Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 

MAJOR JOB DUTIES AND RESPONSIBILITIES: Primary duties may include, but are not limited to:

  • Supervise daily operations of the UM team.
  • Ensure compliance within applicable state program guidelines. 
  • Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
  • Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
  • Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
  • Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
  • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

EDUCATION/EXPERIENCE: Requires an AS/BS in nursing; 3 years of utilization management/quality improvement expeirence. Working knowledge of basic utilization management and quality improvement. Prior experience as a lead area or managing cross functional teams on large projects. 

MUST have excellent computer skills and be able to toggle between multiple systems.  Experience in Excel, Word, Outlook.  Be able to navigate and pick up on new programs quickly! 

 




This position has been closed and is no longer available.
RepuCare

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