Utilization Management
Level of nurses hired to be reviewers
What is an RN
Who are the Care Management Coordinators (aka CMCs)?
What is employees who send out about 3,000 letters per month on behalf of the Care Management department.
The most common source of an appeal
What is a Denial (Denied claim, denied authorization)
Medicare Advantage is looking to expand in 2026
What is Pennsylvania
The number one resource for new employees to your department
What is your SharePoint Site
Criteria used for Inpatient reviews
What is Interqual
HRA (Health Risk Assessment)
What is an assessment of a member’s health conditions, lifestyle factors and SDOH. It is used to determine a member’s risk stratification and develop the care plan for D-SNP members. CMS requires 100% completion for D-SNP members.
Two major types of appeals
What is Claim (post service) and Medical necessity (Pre-service)
Health services has approximately 300 employees, how many do we have within our teams?
What is 200 employees
The recommended time duration options for meetings
What is 30, 45, or 50 mins
# of staff under the UM umbrella and areas covered
What is 72, Inpt, Outpt, Intake, Operations
What is N C Q A - P H M 6?
What is the annual report we submit that measures the effectiveness of the population health/care management program
WOL
What is Waiver of Liability
The LOB that has seen the largest increase in medical cost/utilization over the past 2 years
What is USFHP
The number one meeting platform used between all the departments
What is Zoom
# of cases expected to be completed daily in inpatient and outpatient
What is 20 minimum
What is the Maryland Prenatal Risk Assessment?
What is the form that identifies risk factors for Maryland Medical Assistance participants including medical and psychosocial risk factors associated with poor maternal and newborn outcomes. Maternity
The most common complaint from members
What is Balance billing
Growth opportunities that the recent McKinsey assessment identified for Medicare Advantage
What is PACE/DSNP
The most challenges an admin runs into when scheduling meetings
What is responses
What other depts. does our UM work effect on a regular basis?
What is Case Mgt, Appeals, Medical Directors, Claims, Provider Relations, Medical Policy, Quality, COC, Compliance, Legal, Each LOB, Delegated Vendors, Human Resources, Marketing, IT, Reporting, Facilities, Project Mgt, John Hopkins Home Care, JHM, Finance, Education/Training
What is 30?
What is the # of days a Clinical Quality Care Manager supports an Adv member post discharge
It is important to route appeals or complaints to ACG department asap
What is the Appeal processing timeliness is measured from when the appeal is received by JHHP, not when it is received by the ACG department.
FY 2024 clinical cost of care budget
What is 4.1 million
Most difficult application for administrative professionals to use due to inconstancy
What is SAP