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Utilization Review Nurse RN
4 weeks ago
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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