Job Description

UM Nurse Reviewer

Under the guidance of the Utilization Management, the UM Nurse Reviewer will leverage expertise to conduct timely reviews of pre-certification and/or concurrent requests, aligning with established policies. The UM Nurse Reviewer holds responsibility for ensuring that members receive suitable care at the right time and location, all while adhering to federally and state regulated turn-around times. This role involves reviewing services to guarantee the fulfillment of medical necessity, applying clinical knowledge to ensure proper benefit utilization, facilitating secure and efficient discharge planning, and collaborating closely with internal and external stakeholders to address the multifaceted needs of the member.

Job duties and responsibilities include:

• Performs utilization review activities, including pre-certification, concurrent, and/or retrospective reviews according to regulatory guidelines.
• Reviews proposed hospitalization, home care, and inpatient / outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.
• Determines medical necessity of each request by applying appropriate medical criteria to designated level reviews and utilize approved evidenced-based guidelines or criteria.
• Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type.
• Answers Utilization Management directed telephone calls, managing them in a professional and competent manner.
• Refers case to Medical Reviewer when the request does not meet medical necessity per guidelines, or when guidelines are not available.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information.
• Sends appropriate system-generated letters to providers and members.
• May provide guidance and coaching to other UM nurses and participate in the orientation of newly hired staff.
• Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
• Identify and refer potential cases to Disease Management and Case Management Team.
• For concurrent referrals, ensure that all post-discharge care is coordinated appropriately according to the needs of the member and ensures appropriate continuity of care.
• Participates in Patient-Centered quality improvement initiatives.
• Participates in monthly/quarterly and annual audits.
• Maintain knowledge of DOFR (Disposition of Financial Responsibility), Medicare guidelines, MCG, InterQual, health plan guidelines, and other necessary UM resources.
• Assist in developing workflows, job aid, standard operating procedures, and/or policies and recommend or change as appropriate to ensure timely, efficient, and effective outputs including NCQA, CMS, and other regulatory agencies.
• Participates in data collection, health outcome reporting, clinical audits, and programmatic evaluations.
• Supports patient care database by entering new information as it becomes available, verifying findings and backing-up data.
• Track and trend patient care logs for all required health plans, as needed.
• Ensures clinical documentation is thorough and includes information on transition of care needs of members transitioning from one level of care to another.
• Works with the other support team personnel in a collaborative professional manner to best service the company.
• Identifies high-risk members and conduct necessary interventions, which may include immediate follow-up with Primary Care Physician, community resources such as transportation assistance or programs such as Meals on Wheels for dietary support.
• Presents member cases during Multidisciplinary Rounds to provide update and recommendations on member care status and needs to facilitate safe discharges and prevent avoidable delays during admissions.
• Facilitates access to necessary care by navigating barriers and advocating for members, educating members and families/caregivers on the transition process, options for post-acute care and level set expectations while setting achievable, safe goals.
• Provides technical support and serves as resource to PCP and specialists offices, providers, and members regarding healthcare needs and authorization process.
• Performs all other related duties as assigned.

Qualifications include:

• Active Unrestricted Current California RN or LVN license
• At least one year of managed care experience with prior experience in ambulatory case management, utilization management, disease management or any combination of education/ experience preferred.
• Proficient in PC Software computer skills
• ICD-10, CPT coding knowledge/experience preferred.
• Medicare guidelines, InterQual, or MCG knowledge/experience preferred.
• Excellent communication skills both verbal and written skills
• Solid problem solving and analytical skills.
• Ability to interact productively with individuals and with multidisciplinary teams with minimal guidance.
• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills.

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