Utilization Management Nurse

Summary The primary role of the Utilization Management Nurse is to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes providing prior authorizations, concurrent review, proactive discharge/transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning for members in the hospital and skilled nursing facility. This is primarily a remote telephonic position with normal business day hours, with one weekend day per month coverage. This position serves as a liaison to the Plan Medical Director working closely with appeals and medical decisions. Essential Duties & Responsibilities Performs concurrent and retrospective reviews on all facility and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Evaluates and provides feedback to member’s providers regarding a member’s discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate. As part of the hospital prior authorization process, responsible for determining “observational” vs “acute inpatient” status. Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning. Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation. Maintains accurate records of all communications. Monitors utilization reports to assure compliance with reporting and turnaround times. Addresses care issues with Director of Quality and Care Management and Chief Medical Officer/Medical Director as appropriate. Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transition coordination, discharge planning and issuance of all appropriate authorizations for covered services as needed for providers and members. Coordinates identification and reporting of potential high dollar/utilization cases for appropriate reserve allocation. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Responsible for the early identification of members for potential inclusion in a Chronic Care Improvement Program. Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department. Work as interdisciplinary team member within Medical Management and across all departments. Other duties as assigned. Qualifications Education and Experience: Minimum 2 years clinical experience as RN, LPN/LVN required. Minimum 1-year managed care or equivalent health plan experience preferred. Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required. Medicare Advantage experience preferred. Experience with InterQual or MCG authorization criteria preferred. Excellent computer skills and ability to learn new systems required. Strong attention to detail, organizational skills and interpersonal skills required. Demonstrated ability to problem solve and manage professional relationships. Certificates, Licenses and Registrations Active unrestricted Nursing license required. #J-18808-Ljbffr Curana Health