Role Description
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
• High dollar claims review
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.
• Determines “observational” vs “acute inpatient” status as part of the hospital prior authorization process.
• Actively and proactively engages with member’s providers in proactive discharge/transition planning.
• 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
• 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.
Requirements
• Active unrestricted Nursing license required.
Benefits
• Curana Health has been named the 147th fastest growing, privately owned company in the nation on Inc. magazine’s prestigious Inc. 5000 list.
• Ranked 16th in the “Healthcare & Medical” industry category and 21st in Texas.
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