Outpatient UM Clinician Lead

Job Description

Job Description

Summary

Reporting to the Outpatient UM Supervisor, the Outpatient Clinician Lead is responsible for assuring a thorough review of outpatient precertification / preauthorization referrals for those members identified as having the need for outpatient services. The Outpatient Clinician Lead oversees the clinical team and works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities

• Assist Manager and Lead Coordinator in Health Plan audit responses
• Maintain attendance and coverage for the Clinician team
• Conduct meetings with Clinicians, maintain accurate records of all communications and interventions
• Monitor phone calls & call log for compliance and quality
• Train new team members & provide continuous training of clinical team
• Communicate with Clinicians new policies and health plan updates under guidance of the Manager / Director
• Daily review of referral requests for workflow assignments and compliance timeframes
• Provide advice and counsel to precertification staff
• Review precertification requests for medical necessity
• Communicate with Medical Directors to facilitate medical reviews
• Ability to review cases using applicable criteria per line of business
• As part of the clinical triage program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities
• Establish effective rapport with other employees, professional support service staff, clients, members, families, and physicians
• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to :

o    Promote improved quality of care and / or life

o    Prevent hospitalization when possible and appropriate

o    Prevent complications in members under our care when possible

o    Provide for continuity of care

o    Assure appropriate levels of care are received by members

Minimum Job Requirements

Skill and Abilities