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Job Vacancy Announcement Detail
| Employer: | StayWell Saipan Inc. |
| DBA: | StayWell Saipan Inc. |
| Address: | PO Box 502050 Saipan, Northern Mariana Islands 96950 United States |
| Phone: | 671-477-5091 |
| Other Number: | 670-323-4260 |
| Contact StayWell Saipan Inc. via email | |
| Job Vacancy Announcement | JVA |
| JVA Type: | New |
| Island | Saipan |
| FLSA Covered? | Yes, covered |
| DOD related? | No |
| PERM related? * | No |
| VEVRAA related? | No |
| Original Number of Openings: | 1 |
| Number of Openings Currently Available | 1 |
| Specific Worksite location: | Saipan |
| Job Classification: | Business and Financial Operations Occupations |
| Job Title: | Utlization Management Coordinator |
| Announcement Number: | 20-12-88326 |
| Job Classification: | Business and Financial Operations Occupations |
| Opening Date: | 12/11/2020 |
| Closing Date: | 1/1/2021 |
| Salary Range: | $10.37 to $26.55 / Hourly |
| Job Title: | Utlization Management Coordinator |
| Job Duties: | This is highly responsible and complex professional work in medical underwriting and medical utilization management. This position reviews and analyzes patient records and provider information to determine eligibility for health insurance, as well as medical necessity of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies. communicates to members the various health care options and treatment alternatives to assist them in making informed decisions; performs assurance of quality standards, and performs other related tasks as required. • Manage the medical care coordination functions of the Saipan Branch Office and the nurse coordination tasks of the Philippine Branch Office. Coordinates ambulatory and inpatient care for Plan members and their dependents. • Communicates with the patient, attending physicians, nurses, case managers, social workers, other members of the interdisciplinary healthcare team and patient family members about care options, treatment alternatives, company procedures, and Plan coverage to assist them in making informed decisions about the treatment plan. • Provide a patient-centered, interdisciplinary approach to health care and care coordination using comprehensive, evidenced-based care plans developed in concert with patient/care giver and with the support of the provider. Cultivates a strong, cohesive, team-oriented relationship with practice partners, including on-site and remote interaction where appropriate. • Collaborates with the attending physician and nurse to facilitate off-island referral of patients who need healthcare that is not available in the service area. Review clinical records to determine and recommend the best medical referral option. • Reviews medical records, patient charts and clinical information collected by health support staff and customer care representative to screen insurance applicants based on Company’s Underwriting Guidelines, ensure that care received by the Plan member is consistent with standard of care excellence and to make sure that Health Plan benefit coverage is optimized. • Prepares documents needed for chart review requests and transmit requests to the hospital/clinic/physician offices. • Makes complete chart review of medical records in the hospital/clinic/physician offices and ensure maintenance of confidentiality on information gathered. • Reviews and applies Milliman Care Guidelines (MCG), Medical Society Guidelines, Insurance, governmental and accrediting agency standards to evaluate quality of care as well as to determine coverage for requested healthcare services. • Consults with Medical Director and/or other appropriate programs/resources to overcome barriers to meeting goals and objectives and presents cases to appropriate resources to obtain multidisciplinary view in order to achieve optimal outcomes; daily reporting to the Director of Medical Care Management and the UM-Informed Choice department manager; giving assistance to Nurse coordinators in decision making regarding utilization management issues; and responsible for fostering good relations with existing network of participating provider physicians and facilities. • If necessary, directly contact field representatives, attending physicians, and others to obtain further information. • Collaborate with Chief Actuary and Director of Actuary and Underwriting in deciding whether to offer insurance to the applicant and in determining the appropriate premiums and amounts of coverage. • Creates, updates and maintains records in the Underwriting Department’s database for each application received. • Coordinates with the Health Management Department to ensure the success of Company’s Disease Management program. • Abstracts data from records and maintains statistics and prepares daily and periodic activity reports. Research issues and makes recommendations. • Assigns, reviews, and evaluates the work of professional, technical and clerical staff. • Monitors unusual occurrences, report follow-up procedures, and report monthly and year-to-date comparisons. • Reviews quality assurance standards, studies existing policies and procedures, and interviews personnel and customers to evaluate effectiveness of quality assurance program. Writes quality assurance policies and procedures. • Performs quality-assurance functions to accomplish business coordination, monitoring, and reporting of quality-assurance studies. • Responsible for knowing current QA regulations and information the Director of any new and/or revised regulations imposed. • Compiles statistical data and writs narrative reports summarizing quality assurance findings. • Assists departments with the coordination of audit information and recommends appropriate data-gathering mechanisms, procedures, etc.… • May review patient records, applying utilization review criteria, to determine need for admission and continued stay in hospital. • Reviews StayWell utilization history for applicants who were previously covered with StayWell. • Assists in the evaluation of applicant’s eligibility for coverage in accordance to Company’s regulations and HIPAA rules. • Coordinates and obtains additional medical information from physicians, clinics and other providers for retro-underwriting review of applications. • Assesses and gathers necessary medical information for claim audit review. • Assists in maintaining the files of the department. • Assists in the distribution of clinical record forms and eligibility listing to clinics, physicians and other providers. • Performs other related duties as required. |
| High School Diploma Required? | Yes |
| Qualification Requirements: | • Applicants must have a bachelor's degree in nursing or medicine related field • Minimum of two (2) years’ experience in medical case management and underwriting; and • U.S. and foreign workers must be proficient in Milliman Care Guidelines (MCG) / Medical Society Guidelines |
| Full or Part Time: | Full Time |
| Hours per Week: | 40 |
| Hours per Day: | 8 |
| Payment Frequency: | Bi-Weekly |
| Overtime Available: | Yes |
| Overtime Rate: | $15.55 - $39.83 |
| Rate x 1.5 per hour Exempted: | No |
| Specify All Payroll Deductions: | CNMI Tax FICA |
| Required tools, supplies and Equipment to be provided: | The employee will be provided all tools, supplies and equipment required to perform the duties assigned. |
| Anticipated starting date of employment: | 12/11/2020 |
| Anticipated closing date of employment: | 11/30/2021 |
| Housing Provided: | No |
| Food Provided: | No |
| Transportation required: | No |
| If transportation is required, daily transportation to and from the worksite(s) will be provided to the workers. Daily pick-up place(s) will be at: | 0 |
| Fringe Benefits: | None |
| Comments: | Three-Fourths Guarantee: workers will be offered employment for a total number of work hours equal to at least three-fourths of the workdays of the total period that begins with the first workday after the arrival of the worker at the place of employment or the advertised contractual first date of need, whichever is later, and ends on the expiration date specified in the work contract or in it's extensions, if any. 1. Call 670-323-4260 to pick up an application and submit resumes in person during business hours (Monday to Friday 8:00AM to 5:00PM). 2. Submit an application and resume via email to hr@staywellguam.com during business hours (Monday to Friday 8:00AM to 5:00PM). |