RN Claims Review and Utilization Management

Job Description

Job Description

The utilization review and management (UM) component program ensures that external healthcare services provided across MedTrust/MedHealth contracted facilities are medically necessary, clinically appropriate, evidence-based, and delivered at the appropriate level of care, while supporting regulatory compliance and organizational risk management. The Joint Commission Compliance component ensures MedTrust stays complaint with applicable Joint Commission (JC) standards. MedTrust proudly holds the Gold Seal of Approval from the Joint Commission, recognizing our commitment to quality, safety, and excellence in healthcare staffing. This position ensures that MedTrust/MedHealth is fully compliant in both areas. These two components are referred to below as UMJC.

Essential Functions:

1. Oversee UMJC : Handle the utilization review and management process to ensure the appropriate and cost-effective use of healthcare resources. This includes evaluating treatment plans and ensuring compliance with regulatory requirements. Ensure compliance with JC standards, including file reviews, monthly safety plans and uploading data to the JC web page. This will include assisting with the logging and documentation of claims along the process chain.
2. Collaboration : Work closely with medical staff, case managers, and other healthcare professionals to assess the medical necessity of treatments and coordinate care effectively
3. Data Analysis : Analyze utilization data and trends to identify opportunities for improving efficiency and reducing unnecessary costs. This involves monitoring the performance of healthcare providers and implementing corrective action plans as needed
4. Documentation and Compliance : Maintain accurate documentation of all UMJC activities, ensuring compliance with organizational policies and regulatory requirements. This includes collaborating with hospitals and providers and resolving any utilization-related issues
5. Timeliness : Ensure that claims received are accurately logged and reviewed within seven (7) days of receipt and forwarded promptly to the next step in the process to ensure all claims are ultimately paid timely. It will be this person’s responsibility to notify appropriate management if claims are not being timely received for processing.
6. Quality Improvement Initiatives : Participate in the development and implementation of quality improvement initiatives to enhance patient care outcomes and operational efficiency
7. Joint Commission (JC) Functions : Maintain accurate and up-to-date documentation and compliance records. Serves as the medical lead during joint commission surveys and audits, including preparation of staff and materials. Keeps up-to-date on JC requirements and rules.

Qualifications

• Registered nurse with active, unincumbered nursing licensed in Oklahoma and willing and able to get licensed in other states where MedTrust/MedHealth do business. Master’s degree is preferred.
• Relevant experience in utilization review, utilization management/case management is essential.
• Prior experience with Joint Commission compliance is a plus.
• 3-5 years of healthcare experience required.

Knowledge and Skills

• Analytical Skills : Strong analytical and problem-solving skills to assess data and make informed decisions regarding patient care and resource utilization
• Communication Skills : Excellent communication and interpersonal skills to collaborate effectively with healthcare teams and patients
• Knowledge of Regulations : Familiarity with healthcare regulations, insurance policies, and quality improvement processes is crucial for success in these roles
• Knowledge of Joint Commission : Familiarity with joint commission requirements and duties.
• Working knowledge of and familiarity with Microsoft Word and Excel .
• Strong organization skills, with ability to work in fast paced environment.

Working Conditions and Environment

• Must pay attention to detail-visual & mental
• Must be able to multi-task
• Ability to work independently without direct supervision
• Ability to perform under stress
• Ability to work with individuals at all levels of the organization to foster teamwork
• While varied hours are required occasionally, normal office hours are 8 am – 5 pm with one hour for lunch
• This is an in-office, no remote work capability position

Travel

• Some travel may be required, but should be minimal and notice will be provided if necessary

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