Medical Management Auditor, Trainer
Job Description:
• Conduct Utilization Reviews: Review patient treatment plans, medical records, and healthcare services for appropriateness and adherence to managed care guidelines.
• Perform both retrospective and concurrent reviews of medical cases to ensure that healthcare services provided align with medical necessity standards.
• Audit the use of healthcare resources and ensure that services, such as inpatient stays, diagnostics, and procedures, are justified.
• Evaluate Medical Necessity and Clinical Decisions: Assess the clinical appropriateness of services rendered by reviewing the patient’s health status, history, and treatment protocols.
• Ensure that services provided meet medical necessity criteria and follow evidence-based guidelines established by the managed care organization.
• Regulatory and Payer Compliance: Ensure that healthcare services comply with both federal and state regulations, as well as the specific policies of managed care plans.
• Evaluate the correct application of payer guidelines and ensure proper documentation.
• Documentation and Reporting: Maintain accurate and thorough documentation of audit findings, including recommendations for corrective actions or process improvements.
• Prepare detailed audit reports summarizing findings, trends, and opportunities for cost savings or improvements in care delivery.
• Communicate audit results to relevant departments, including case management, utilization management, and senior leadership.
• Collaboration and Communication: Work closely with physicians, case managers, and other healthcare professionals to assess and improve utilization management processes.
• Provide education and guidance on appropriate care utilization, proper documentation practices, and managed care guidelines.
• Collaborate with medical directors and utilization management teams to optimize patient care and reduce unnecessary service use.
• Trend and Data Analysis: Monitor and analyze utilization trends to identify opportunities for cost reductions, process efficiencies, and improvements in care.
• Provide reports on trends related to high-cost services, frequent readmissions, and other areas of concern in managed care programs.
• Recommend best practices for improving patient care while minimizing unnecessary resource utilization.
• Continuous Improvement and Quality Assurance: Participate in quality improvement initiatives, focusing on improving the managed care utilization management processes.
• Suggest process improvements to enhance the efficiency of the utilization management function and improve care quality.
• Deliver training to the team or individual staff members based on audit findings or new process improvement outcomes.
• Stay updated on industry trends, regulatory changes, and new healthcare technologies or guidelines.
Requirements:
• Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or a related field.
• Clinical credentials such as Registered Nurse (RN) or Licensed Practical Nurse (LPN) are often preferred.
• At least 2-3 years of experience in utilization management, healthcare auditing, or managed care, with a strong understanding of medical necessity and managed care systems.
• Familiarity with utilization management concepts, including prospective, concurrent, and retrospective review processes.
• Knowledge of payer policies and insurance coverage.
• Understanding of quality improvement, cost management, and healthcare compliance.
• Relevant certifications such as Certified Case Manager (CCM) or Utilization Management Certification (CUMC) may be preferred or required.
• Strong analytical and critical thinking abilities for reviewing medical records and identifying discrepancies.
• Proficiency in electronic health records (EHR) and utilization management software.
• Excellent written and verbal communication skills, including the ability to prepare detailed reports.
• Strong organizational skills with attention to detail and the ability to manage multiple tasks simultaneously.
Benefits:
• Health benefits
• Life and disability benefits
• 401(k) savings plan with match
• Paid Time Off
• Paid holidays
Apply Now
Apply Now
• Conduct Utilization Reviews: Review patient treatment plans, medical records, and healthcare services for appropriateness and adherence to managed care guidelines.
• Perform both retrospective and concurrent reviews of medical cases to ensure that healthcare services provided align with medical necessity standards.
• Audit the use of healthcare resources and ensure that services, such as inpatient stays, diagnostics, and procedures, are justified.
• Evaluate Medical Necessity and Clinical Decisions: Assess the clinical appropriateness of services rendered by reviewing the patient’s health status, history, and treatment protocols.
• Ensure that services provided meet medical necessity criteria and follow evidence-based guidelines established by the managed care organization.
• Regulatory and Payer Compliance: Ensure that healthcare services comply with both federal and state regulations, as well as the specific policies of managed care plans.
• Evaluate the correct application of payer guidelines and ensure proper documentation.
• Documentation and Reporting: Maintain accurate and thorough documentation of audit findings, including recommendations for corrective actions or process improvements.
• Prepare detailed audit reports summarizing findings, trends, and opportunities for cost savings or improvements in care delivery.
• Communicate audit results to relevant departments, including case management, utilization management, and senior leadership.
• Collaboration and Communication: Work closely with physicians, case managers, and other healthcare professionals to assess and improve utilization management processes.
• Provide education and guidance on appropriate care utilization, proper documentation practices, and managed care guidelines.
• Collaborate with medical directors and utilization management teams to optimize patient care and reduce unnecessary service use.
• Trend and Data Analysis: Monitor and analyze utilization trends to identify opportunities for cost reductions, process efficiencies, and improvements in care.
• Provide reports on trends related to high-cost services, frequent readmissions, and other areas of concern in managed care programs.
• Recommend best practices for improving patient care while minimizing unnecessary resource utilization.
• Continuous Improvement and Quality Assurance: Participate in quality improvement initiatives, focusing on improving the managed care utilization management processes.
• Suggest process improvements to enhance the efficiency of the utilization management function and improve care quality.
• Deliver training to the team or individual staff members based on audit findings or new process improvement outcomes.
• Stay updated on industry trends, regulatory changes, and new healthcare technologies or guidelines.
Requirements:
• Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or a related field.
• Clinical credentials such as Registered Nurse (RN) or Licensed Practical Nurse (LPN) are often preferred.
• At least 2-3 years of experience in utilization management, healthcare auditing, or managed care, with a strong understanding of medical necessity and managed care systems.
• Familiarity with utilization management concepts, including prospective, concurrent, and retrospective review processes.
• Knowledge of payer policies and insurance coverage.
• Understanding of quality improvement, cost management, and healthcare compliance.
• Relevant certifications such as Certified Case Manager (CCM) or Utilization Management Certification (CUMC) may be preferred or required.
• Strong analytical and critical thinking abilities for reviewing medical records and identifying discrepancies.
• Proficiency in electronic health records (EHR) and utilization management software.
• Excellent written and verbal communication skills, including the ability to prepare detailed reports.
• Strong organizational skills with attention to detail and the ability to manage multiple tasks simultaneously.
Benefits:
• Health benefits
• Life and disability benefits
• 401(k) savings plan with match
• Paid Time Off
• Paid holidays
Apply Now
Apply Now