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Position Summary
The Utilization Review Nurse works as a member of a team responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations.
This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, receives and reviews notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes.
The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
-Ensure members are receiving appropriate level of care
-Promote cost effective medical outcomes
-Prevent hospitalization/ readmissions when appropriate
-Promote decreased lengths of hospital stays when appropriate
-Provide for continuity of care
Job Description
Key Outcomes/Results:
- Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
- Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
- Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues
- Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to: authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.
- Coordinates referrals to Care Management, as appropriate.
- Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.
- Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
- Participates as a member of an interdisciplinary team in the Health Management Department
- May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team
- Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
- Mentors new staff into case management role as assigned.
- Assumes extra duties as assigned based on business needs.
- Participates on committees, work groups, team rounds, and/or projects as designated.
- Attends on-going training/continuing education, at a minimum annually, to maintain professional competency.
- Assists in creation and updating of department Policies and Procedures.
- Participates in quality initiatives and process improvements that reinforce best practice medical management programming and offerings.
Education/Experience:
- Unrestricted state license as a Registered Nurse required; BSN preferred.
- 3+ (total) years clinical nursing experience
- Utilization management experience in a managed care or hospital environment required
- Certification in managed care nursing or care management desired (CMCN or CCM)
Required License(s) and/or Certification(s):
- Unrestricted state license as a Registered Nurse
Skills/Knowledge/Competencies (Behaviors):
- Demonstrates an understanding of and alignment with Martin’s Point Values.
- Maintains current licensure and practices within scope of license for current state of residence.
- Maintains contemporary knowledge of evidence - based guidelines and applies them consistently and appropriately.
- Ability to analyze data metrics, outcomes and trends.
- Excellent interpersonal, verbal and written communication skills
- Critical thinking: can identify root causes and understands coordination of medical and clinical information
- Ability to prioritize time and tasks efficiently and effectively
- Ability to manage multiple demands
- Ability to function independently
- Computer proficiency in Microsoft Office products including Word, Excel, and Outlook
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at:jobinquiries@martinspoint.org
