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Position SummaryThe Utilization Review Nurse works as is 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, 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 receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.
Job Description
Key Outcomes:
- 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
- Establishes and maintains strong professional relationships with community providers.
- Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
- Mentors new staff as assigned.
- Meets or exceeds department quality audit scores.
- Meets or exceeds department productivity.
- Assists in creation and updating of department policies and procedures.
- Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
- Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
- Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
- Assumes extra duties as assigned based on business needs, including weekend rotations
Education/Experience:
- 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
- 2+ years of utilization management experience in a health plan UM department
Required License(s) and/or Certification(s):
- Compact RN License
- Certification in managed care nursing or care management desired (CMCN or CCM)
- Coding/CPC desired
Skills/Knowledge/Competencies (Behaviors):
Proficiency in conducting prospective, concurrent, and retrospective reviews using standardized criteria and guidelines like MCG
Ability to review and interpret medical records, treatment plans, and clinical documentation, with a keen eye for detail and compliance with healthcare standards
Thorough understanding of healthcare policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE)
Familiarity with coding systems like ICD-10 and CPT
Technical savvy and ability to navigate multiple systems and screens while working cases
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 knowledge of Scope of Nursing Practice in states where licensed.
- 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.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org
Do you have a question about careers at Martin’s Point Health Care? Contact us at:jobinquiries@martinspoint.org
Originally posted on Himalayas