Job Description

Especialista de Utilizacion Medica

Regular


Exempt

GENERAL DESCRIPTION:

The Medical Utilization Specialist works with patients with high medication utilization, specialty physicians, PCP visits, hospital and emergency room admissions, readmissions, etc., to develop an individualized care plan aimed at improving utilization. Educates patients regarding utilization of medications, treatments, conditions, and other related areas. Additionally, works with physicians to manage (in a cost-effective manner) the necessary services to maintain an optimal level of health for high-risk patients and facilitate access to services for these patients.

ESSENTIAL FUNCTIONS:

Validates those incoming cases potentially meet the criteria for receiving services from the Unit. Works with patients with high utilization of medications, specialty physicians, PCP visits, hospital and emergency room admissions, and readmissions, among others, to develop an individualized plan of care aimed at improving utilization. Assesses the policyholder's condition to identify each patient's individual needs, such as:

o whether they are high-risk


o they are frail, disabled, have comorbidities, chronic, catastrophic conditions, or are institutionalized


o they meet the criteria for admission to the various MCS Care Management Programs

Establishes an individualized plan of care with specific goals for each patient enrolled in the program, using clinical

judgment and clinical guidelines adopted by MCS.Proactively identifies problems and barriers that may affect the insured by establishing achievable goals and short or long-term management strategies. Plans the care of the insured, taking into consideration the identified needs. Makes referrals (clinical/non-clinical) to the different members of the interdisciplinary team according to the insured's needs. Documents the progress of the insured's condition and all actions taken following the policies and procedures established in the Unit. Maintains effective communication about the patient's condition and treatment with the physician, service provider, and patient. Evaluate the effectiveness of patient treatment as needed and participate in case discussions with Providers when re-evaluation of the plan of care and coordination of necessary services is required. Educates patients regarding adherence to medications, treatments, conditions, and other related areas to maximize resources and decrease utilization. Establishes communication with physicians to manage cost-effectively the necessary services to maintain an optimal level of high-risk patients' health and facilitate access to services. Coordinates meetings between PCP and MCS as needed. Performs casework reports and interventions, as requested. May perform other duties and responsibilities as assigned, in accordance with the education and experience requirements contained in this document. Complies fully and consistently with company standards, policies, procedures, and local and federal laws applicable to our industry, business, code of conduct, and employment practices.

MINIMUM QUALIFICATIONS:

Education and experience:

Bachelor's degree in Nursing Sciences. At least three (3) years of experience in the direct care of patients with chronic health conditions, preferably within the Health Insurance Industry.

Certifications/Licenses:

A valid Nursing and Registration license is required

Other:

Good command of computer systems such as MS Office, among others.

Languages:

Spanish -

Intermediate (comprehensive, writing and verbal)

English -

Intermediate (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Accion Afirmativa para reclutar a Mujeres, Minorias, Veteranos Protegidos y Personas con Impedimento

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