a. Provide members and health care providers with appropriate and timely prior approval, pre-service and continued stay reviews determinations and Wellmark Health Plan of Iowa WHPI out of network utilization management service and support prior to providing hospital and/or clinical services by obtaining medical information necessary to make a clinical determination based on appropriate medical policy or criteria. Interact with Wellmark Medical Director, physician consultants and/ or vendors as appropriate.
b. Provide utilization management service, prior approval pre-service review determinations and or continued stay reviews and support to members while located in an acute health care facility, skilled or other level of care facility, or home health care admissions. Process utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria InterQual, and benefit information for internal/external customers within the timeframes described in the requirements. Interact with Wellmark Medical Director, as appropriate for levels of care that do not meet medical criteria.
c. Work with health care provider staff in a courteous and professional manner in gathering medical information to ensure accurate diagnosis codes for documentation and reporting purposes. Influence, collaborate and negotiate with providers in an open, direct and supportive manner to resolve conflicts, utilization review issues and alternative treatment setting options.
d. Responsible for the utilization review process, monitoring patients progress, screening and assessing for discharge and transition of care planning needs. Identify key issues and barriers to discharge ensure development and facilitation of discharge plan.
e. Work in collaboration with other health care management teams and stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member, coordinate care and make appropriate referrals to other Health and Care Management programs. Meet both quality assurance and production metrics as established for the utilization management unit.
f. Document events accurately, consistently and timely within CCMS by following the standard work guidelines and policies to support internal and external processes, including documentation of potential avoidable days/ admission when medical necessity criteria are not met. Communicate approval and denial notifications and decisions to members and/or providers using both verbal and written communication. Log denials as appropriate.
g. Comply with regulatory standards, accreditation standards and internal guidelines remains current and consistent with the standards pertinent to Utilization Management Services.
h. Other duties as assigned.