Utilization Review is the process in which medical review determinations are made based on clinical guidelines and structured processes. This position reviews the utilization of the organization/plan’s resources against established criteria, monitors and evaluates the medical necessity, appropriateness and efficient use of health care services. The position also provides reports and recommendations for improved utilization of resources while maintaining quality of care to the UM/CM Mgr., Director of Managed Care and the Chief of Managed Care.
Essential Duties and Responsibilities:
Includes the following. Other duties may be assigned.
Participation in AHF Meetings/Committees
Attends AHF meetings as assigned.
This job has no supervisory responsibilities.
To perform this job successfully, an individual must be able to satisfactorily perform the essential duties. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent to draw and interpret bar graphs. College level algebra and statistics
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.