Utilization Management Director. The Utilization Management Director must: Be an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board with experience in the activities of utilization management, in accordance with 42 CFR 438.210; Preferably be certified as a Certified Professional in Health Care Quality by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers; and The Utilization Management Director's primary responsibilities are to: Oversee the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines; Develop written policies and procedures regarding authorization of services and monitor to ensure that these are followed; Ensure the consistent application of review criteria for authorization decisions; Ensure that decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease; Ensure MCO Notices of Adverse Action are provided in accordance with 42 CFR 438.404; Ensure that all authorization decisions are made within the specified allowable timeframes; and Evaluate under and over utilization information for impact on member quality of care and outcomes, including access to care.
Appears in 4 contracts
Samples: Ohio Medicaid Provider Agreement for Managed Care Organization, Ohio Medicaid Provider Agreement for Managed Care Organization, Ohio Medicaid Provider Agreement for Managed Care Organization
