Utilization Review Nurse

Quality Management Specialist

Participates in the development and ongoing implementation of QM Work Plan activities. Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives.

Responsibilities:

• Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Data gathering requires navigation through multiple system applications.
• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Responsible for the review and evaluation of clinical information and documentation.
• Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
• Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
• Independently coordinates the clinical resolution with internal/external clinician support as required.
• Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
• Prepares and completes QM documents based on interpretation and application of business requirements
• Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
• Assists in the development and implementation of QM projects and activities
• Accountable for completing and implementation of QM Work Plan Activities

Experience:

• 3+ years of experience as an RN
• Registered Nurse in state of residence
• Must have prior authorization utilization experience
• Experience with Medcompass

Skills:

• MUST HAVE MEDCOMPASS or ASSURECARE exp.
• MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
• MUST HAVE UM experience, inpatient utilization management review.
• MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
• MUST HAVE 6 months of Prior Authorization.

Education:

• Active and unrestricted RN licensure in state of residence

Questionnaire:

• Do you have experience with Medcompass?
• Do you have experience with Prior Authorization?
• Do you have experience with Utilization Review?
• Do you have an Active Registered Nurse License?

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