Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 employees dedicated to serving their health plan members.
Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.
In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers' compensation, as well as vocational rehabilitation, life-care planning and wellness.
As a part of ProMedica, Paramount is driven by ProMedica's mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website at paramounthealthcare.com
REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES
This position reports to the UM manager with daily supervision by an assigned Team Lead.
No positions report to this position.
POSITION SUMMARY
The UM Coordinator reviews submitted clinical information for prior authorization requests, acute care initial, concurrent and post-discharge, LTAC, SNF, home health authorizations, and outpatient/ambulatory services. Assist with transition of care needs including referrals to case management, behavioral health, population health, and disease management.
ACCOUNTABILITIES
Perform effective preadmission, initial, concurrent, and post-discharge medical management for outpatient/ambulatory, inpatient, LTAC, SNF, and home health authorizations. Identify members for potential case management and referral needs. Reviews clinical submitted by providers to identify any transition of care needs and assists with this process.
Authorize and facilitate ambulatory services, acute care/post-acute care, and home health care as well as out-of-plan services, considering the member's individual needs, and utilizing panel providers whenever possible for cost-effectiveness.
Precertify/certify and concurrently review requests for care utilizing InterQualR level of care criteria to ensure appropriate medical care in the most cost-effective setting. Utilize nursing education and experience to evaluate the appropriateness of requests relative to the member's diagnosis(es)/condition.
Assess all members receiving care for post-discharge or Case Management needs. Refer members directly to Case, Behavioral, or Disease Management (depending on the product) to ensure that the member receives appropriate medical care and services, in the most cost-effective setting, to maintain or improve health status when possible, and prevent avoidable readmissions.
As appropriate, collaborate with hospital discharge planning staff to identify an appropriate post-discharge plan of care for hospitalized members. Confer with physician offices, ancillary providers, Plan Case Managers, and Medical Directors on pertinent case questions or situations when evaluation or decision is beyond the scope of the Coordinator. Send post-discharge letters, as appropriate, to follow up and further assess the member's situation, functioning, and compliance with the follow-up plan.
Document ambulatory and inpatient medical management, in the appropriate system applications, according to current Company and Department policies and procedures. Complete all related reporting documentation according to established timeframes. Comply with all Federal, State, accreditation, professional and corporate regulations, standards, and policies pertaining to privacy and confidentiality.
Identify potential high-dollar cases and collaborate with the Finance Department on case-specific expected risks;
Report any quality issues identified during clinical documentation review. Identify and report any concerns for fraud, waste, and abuse to the internal investigation unit.
Enforce prior authorization contract language and regulatory compliance requirements for network providers. Enforce regulatory compliance requirements for out-of-network providers.
Initiate single case agreement requests with out-of-network providers and initiate sanction/exclusion investigation review for out-of-network provider requests.
Assist in the investigation of provider complaints and regulatory complaints when warranted.
Perform other duties as directed.
REQUIRED QUALIFICATIONS
Education: Associates Degree in Nursing
Skills: Excellent interpersonal, communication (oral and written), and organizational skills required. Ability to plan, coordinate and organize multiple priorities.
Basic PC skills: Windows, word processing, email
Years of Experience: Minimum 2-3 years recent clinical or utilization review/medical management experience
License: Current Ohio and Michigan nursing license (Michigan registered nurse's license must be obtained within three months of employment or transfer into position)
PREFERRED QUALIFICATIONS
Education: Bachelor's Degree in Nursing
Skills: Knowledge of InterQualR criteria (or similar); knowledge of ICD, CPT, and DRG coding preferred.
Years of Experience: 3-5 years of clinical experience, with a utilization management background
License: Ohio, Michigan, Indiana
Certification:
WORKING CONDITIONS
Personal Protective Equipment:
Physical Demands: Ability to move between company workstations and departments
ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org
Equal Opportunity Employer/Drug-Free Workplace
Equal Opportunity Employer
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica Senior Care, please contact jobline@hcr-manorcare.com.
