The Utilization Management Nurse Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.
The Utilization Management Nurse Reviewer works with healthcare providers to ensure appropriate approval of plan benefits. This is accomplished by reviewing clinical information provided to assess medical necessity and the appropriateness of the treatment setting through the application of appropriate policies and criteria (i.e. Milliman). Case assignments may fall in various areas, such as concurrent review of inpatient services, discharge planning, retrospective review, and special needs facilities (SNF).
Current Active and Unrestricted Nursing License required ( Associate Degree, Nursing Diploma or Bachelor's degree in Nursing)
3 years combined clinical and utilization management experience in a managed health care plan preferred
Bachelor's Degree in Nursing preferred with 3-5 years of clinical experience in Utilization Review
Required experience in utilization management to include utilization review, concurrent review, discharge planning, transitional care and Skilled nursing review.
Knowledge of Medicaid, Commercial or Medicare Managed Care programs and regulations
Experience & Education:
Experience using and applying InterQual & MCG clinical guidelines
Comprehensive understanding of standards such as NCQA, URAC, CMS (Medicare/Medicaid) and their application in a managed care setting
Excellent analytical-thinking/problem-solving skills
Ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads
Excellent interpersonal skills required
Intermediate Microsoft Word, Excel, Outlook & PowerPoint skills
Performs utilization management reviews in accordance with federal and state regulations
Maintains compliance with regulatory changes affecting utilization management
Perform UM reviews (prospective/concurrent/retrospective) for inpatient services according to the NCQA, URAC, CMA & DOH standards and client requirements and/or policies
Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer
Adheres to Department of Labor, state and UM timeframe requirements per contract
Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
Tracks status of all utilization management reviews in progress
Releases UM determinations to claim stakeholders following client-established protocols
Works closely with management team in the ongoing development and implementation of utilization management programs
Certifies reviews that meet clinical review criteria/guidelines
Adheres to quality standards and UM guidelines
Maintains all required utilization management review documentation in the UM software in a timely manner
Refer cases to case management as indicated/appropriate
Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established proto
Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols
Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives
Learns new methods and services as the job requires
Advises supervisor of any potential problems as they become evident
Manages assigned workload within established performance & productivity standards
Attends meetings to achieve departmental goals and objectives
Able to work rotational shifts with adherence to schedule a must, including evenings, weekends, holidays and overtime as necessary
Performs other projects and duties as assigned
Domain SkillsSNoPrimary SkillProficiency Level *Rqrd./Dsrd.1Utilizn Mgmt-Nurse ReviewNADesired2Medical ManagementNADesired
* Proficiency LegendsProficiency LevelGeneric ReferencePL1The associate has basic awareness and comprehension of the skill and is in the process of acquiring this skill through various channels.PL2The associate possesses working knowledge of the skill, and can actively and independently apply this skill in engagements and projects.PL3The associate has comprehensive, in-depth and specialized knowledge of the skill. She / he has extensively demonstrated successful application of the skill in engagements or projects.PL4The associate can function as a subject matter expert for this skill. The associate is capable of analyzing, evaluating and synthesizing solutions using the skill.
Employee Status : Full Time Employee
Shift : Day Job
Travel : No
Job Posting : Oct 23 2019
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