Utilization Review Nurse RN

3 months ago

Dubai, United Arab Emirates ClickJobs.io Full time

Victorville, CA

  • Coordinates and reviews all medicalrecords, as assigned to caseload
  • Activelyparticipates in Case Management and Treatment Teammeetings
  • Serves as on-going educator to alldepartments
  • Responsible for reviewing patientcharts in order to assess whether the criteria for admission andcontinuation of treatment is being met; gathering data andresponding to request for records from fiscal intermediary;gathering clinical and fiscal information and communicating statusof both open and closed accounts for multiple levels of UtilizationReview and Case Management reporting
  • Able towork independently and use soundjudgment.
  • Knowledge of Federal, State, andintermediary guidelines related to inpatient, acute carehospitalization, as well as lower levels of care for the continuityof treatment.
  • Coordinates discharge referralsas requested by clinical staff, fiscal intermediary, patients, andfamilies.
  • Responsible for providing timely andaccurate referral determination
  • Identificationof referrals to the medical director forreview
  • Appropriate letter language and coding(denials, deferrals, modifications)
  • Appropriateselection of the preferred and contractedproviders
  • Proper identification of eligibilityand health plan benefits
  • Proper coding totrigger the record to be routed to a different work queue or totrigger the proper determination notice to be sentout
  • Responsible for working closely withsupervisor/lead to address issues and delays that can cause afailure to meet or maintain compliance.
  • Meetsor exceeds production and quality metrics.
  • Workdirectly with the provider(s) and health plan Medical Director tofacilitate quality service to the member andprovider.
  • Identifies Clinical Programopportunities and refers members to the appropriate healthcareprogram (e.g. case management, engagement team, and diseasemanagement)..
  • Maintains and keeps in totalconfidence, all files, documents and records that pertain to thebusiness operations.
  • Performs other duties asassigned.

EDUCATION &EXPERIENCE REQUIREMENTS:

  • CA LVN license required. CA RNlicense preferred.
  • Bachelor’s orMaster’s degree in Social Work, behavioral or mentalhealth, nursing or other related health fieldpreferred
  • 3 to 5 years of acute care experiencepreferred.
  • Two (2) years managed careexperience in UM/CM Department, preferred

SKILLS &ABILITIES REQUIREMENTS:

  • Knowledge of CMS, State Regulations,URAC and NCQA guidelines preferred.
  • ICD-9 andCPT coding experience a plus
  • Experiencedcomputer skills with Microsoft Word, Microsoft Outlook, Excel andexperience working in a health plan medical managementdocumentation system a plus
  • Experience inEZ-CAP preferred
  • Medical Terminologypreferred

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