Who we are:
Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.
We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.
Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.
A Day in the Life of a Utilization Management Pre-Service Review Nurse - Medicare:
This position works collaboratively with members, providers, and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care for Utilization Management- including Utilization Management Care Coordinators, Denials Team, and Medical Directors to ensure timely disposition of pre-service authorization requests. This position is also responsible for ensuring that authorization requests, provider inquiries and member inquiries are handled appropriately within established timeframes, established guidelines and protocol are utilized for clinical decision-making.Responsibilities
- Perform review of requests for services/procedures including, but not limited to, elective surgery (inpatient and outpatient), Durable Medical Equipment, home care, therapy services, and IV infusions that require medical necessity review and/or benefit interpretation
- Use established medical criteria to approve services based on information obtained from attending physician and/or other providers
- Ensure timely disposition of requests according to established timeframes
- Consult with Medical Director as appropriate for all requests that do not meet criteria and inform providers of the Medical Director’s decisions
- Ensure full collection of clinical information prior to rendering a decision
- Act as a member/family advocate in coordinating and accessing medical necessity health care services within the benefit plan
- Respond to member questions regarding the disposition of a request and/or the decision
- Manage workload needs on a concurrent basis, including authorization queues and fax queues in the UM department to concurrently prioritize self-assignment for greatest impact on department function
- Support orientation program for UM staff by acting as primary mentor for all UM Medicare family member
- In conjunction with leadership, act as resource for criteria and benefit interpretation including the correct and consistent application of the InterQual, CMS, LCD, NCD criteria on the appropriate topics, consistent application of procedural practices established by MHP
- Supply ongoing training and education to the staff through one-on-one and classroom settings regarding InterQual, National Committee for Quality Assurance (NCQA), URAC, CMS or general accreditation, MDCH and other necessary job-related skills
- Collaborates with the Disease Management, Quality Management, and Utilization Management departments in the development of protocols and guidelines designed to standardize care practice and care delivery. Seeks out opportunities to improve HEDIS, NCQA, URAC, CMS or general accreditation and QIA activities
- Complete authorization process in MCS system for approved authorizations and contact providers & member with decision and corporate authorization number
- Contact provider and members where additional information is necessary to make a decision
- Receive and process clinical updates for continuation of services
- Collaborate with inpatient reviewers, case managers and other UM - Medicare staff for care coordination
- Maintains department productivity and quality measures
- Adheres to Utilization Management policies and procedures
What you can bring to Meridian:
- Knowledge of medical terminology, authorization processes, Medicaid/ Medicare and Managed Care
- Proficient in InterQual
- Current license (without restriction) to practice as a Licensed Practical Nurse or Registered Nurse in the designated State is required
- At least one year experience in UM/UR and managed care experience is preferred
- Excellent customer service and interpersonal communication skills
- Excellent computer/data entry skills
What Meridian can offer you:
- Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
- Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
- Meridian offers 401k matching that is above the national average.
- Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
- Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.
Equal Opportunity Employer