Utilization Management Manager. The Contractor shall employ a Utilization Management Manager who is dedicated full-time to the Contractor’s Indiana Medicaid product lines. The Utilization Management Manager shall, at a minimum, be responsible for directing the activities of the utilization management staff. With direct supervision by the Medical Director, the Utilization Management Manager shall direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs. The Utilization Management Manager shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action. For more information regarding the utilization management requirements, see Section 6.
Utilization Management Manager. The Contractor must employ a Utilization Management Manager who is dedicated full-time to the Hoosier Care Connect program. The Utilization Management Manager must, at a minimum, be responsible for directing the activities of the utilization management staff. With direct supervision by the Medical Director, the Utilization Management Manager must direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs. The Utilization Management Manager (or Claims Manager, as applicable) shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action. For more information regarding the utilization management requirements, see Section 7.3.
Utilization Management Manager. The Contractor shall employ a Utilization Management Manager who is dedicated full-time to the Contractor’s Indiana EXHIBIT 1.A
Utilization Management Manager. The Contractor must employ a Utilization Management Manager who is dedicated full-time to the PathWays program. The Utilization Management Manager shall be responsible for directing the activities of the utilization management staff. With direct supervision by the Medical Director and a staff geriatrician, the Utilization Management Manager shall direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, and other clinical and medical management programs. The Utilization Management Manager shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action. For more information regarding the utilization management requirements, see Section 7.8. The Utilization Management Manager shall have prior experience in LTSS or with the program population.
Utilization Management Manager. The MCO must employ a Utilization Management Manager who is dedicated full-time to the Hoosier Healthwise program. This Manager must, at a minimum, be responsible for directing the activities of the utilization management staff within the patient confidentiality guidelines mandated by the Health Insurance Portability and Accountability Act (HIPPA). This Manager must direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retro-review, continuity of care, care coordination and other clinical and medical management programs. For more information regarding the utilization management requirements, see Section 5.0 of this Attachment. • Financial Officer – A financial officer must oversee the budget and accounting systems of the MCO for the Hoosier Healthwise program. This Officer must, at a minimum, be responsible for ensuring that the MCO meets the State’s requirements for financial performance reporting.
Utilization Management Manager. The Contractor shall employ a Utilization Management Manager who is dedicated full-time to the Contractor’s Indiana Medicaid product lines. The Utilization Management Manager shall, at a minimum, be responsible for directing the activities of the utilization management staff. With direct supervision by the Medical Director, the Utilization Management Manager shall direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN programs. The Utilization Management Manager shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action. For more information regarding the utilization management requirements, see Section 6.3.
Utilization Management Manager. Shall be an Iowa licensed registered nurse, physician or physician’s assistant if required to make medical necessity determinations. This position manages all elements of the Contractor’s UM program and staff under the supervision of the Medical Director. This includes but is not limited to functions related to Prior Authorization, medical necessity determinations, concurrent and retrospective reviews, and other clinical and medical management programs as described in the Contract.
