Job Description

Job Title: Clinical Utilization Management Reviewers

No of Vacances: 05

Target Start Date: 15 January 2021

Job Description: A Clinical Utilization Management Reviewer will be required to work on medical related projects as below stated

Clinical Duties:-

1) Perform Utilization Management (UM) reviews in accordance with mandated regulations. Maintains compliance with regulatory changes affecting UM.

2) Perform UM reviews (prospective/concurrent/retrospective) for inpatient and outpatient services according to the prescribed standards and client requirements and/or policies.

3) Review UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.

4) Adheres to Department of Labor, State, and company UM time frame requirements.

5) Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.

6) Tracks status of all UM in progress.

7) Releases UM determinations to claim stakeholders following client-established protocols.

8) Works closely with management team in the ongoing development and implementation of UM programs.

9) Certifies reviews that meet clinical review criteria/guidelines.

10) Adheres to quality standards and State UM guidelines.

11) Maintains all required UM review documentation in the UM software in a timely manner.

12) Serves as first level contact for customer complaint resolution.

13) Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols

14) Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks

Job Responsibilities:-

1) Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.

2) Manages assigned workload within established performance standards.

3) Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.

4) Learns new methods and services as the job requires.

5) Advises supervisor of any potential problems as they become evident

6) Performs other duties as assigned or required

1. Required Qualifications, Experience and Skills

a)Must be a BScN – Bachelor of Science in Nursing or KRCHN – Kenya Registered Community Health Nurse

b) Must have must have completed the Nursing Council License Exam and have an active and current RN Practice License and Registration Certificate from the Nursing Council of Kenya (NCK).

c) Must have relevant experience of 2+ years

2. For OTHER HEALTH SCIENCES PROFESSIONALS:

a) Must be a Registered Professional in their respective field.

b) Must have an active, current and unrestricted relevant Professional license issued by the Kenya Medical Practitioners and Dentists Council (KMPDC), have relevant years of clinical BPO experience in any of or similar Must domains of Utilization Management, Case Management, Disease Management, Wellness, Medical Coding and Billing, Pharmacy Benefits Management in any of the industry sectors of Workers’ Compensation; Commercial Managed Care; Health, Disability, Life, Property and Casualty Insurance; Accountable Care Organizations (ACO’s) or any other sector wherein the work performed is related to the use of clinical knowledge and skills.

3) Knowledge of nursing principles, techniques, and procedures for the care of patients.

4) Knowledge of medical terminology, anatomy, physiology and concepts of disease

5) Makes sound clinical decisions in a timely manner

6) Can potentially define whether a person qualifies for insurance medical cover or is eligible for Medical benefit etc.

Skills

1) Must be proficient in utilizing relevant technologies and system applications commonly used in Health Care Management

2) Work in an intensive, fast-paced environment with minimal supervision

3) Ability to stay organized and interact well with others in any situation

4) Provide daily updates to Manager of Utilization Management for review

5) Must be willing to work rotational shifts with adherence to schedule, including evenings, weekends and overtime as necessary

6) Must be detail oriented and possess good organizational skills

7) Must have effective written and oral communication skills and be able to maintain confidentiality

8) Must have excellent interpersonal skills and team oriented to work in a high stress environment

9) Able to handle multiple tasks and shifting priorities

10) Ability to work on projects and meet deadlines

If you think you are the one we are looking for: We invite you to send your Applications to kenya@adec-innovations.com, not later than 11th January 2021.

Job Location: ATHI RIVER

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