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Review Nurse RN
1 month ago
Victorville, CAJob Responsibilities:Coordinates and reviews all medical records, as assigned to caseload.Actively participates in Case Management and Treatment Team meetings.Serves as on-going educator to all departments.Responsible for reviewing patient charts to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to requests for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting.Able to work independently and use sound judgment.Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.Responsible for providing timely and accurate referral determination.Identification of referrals to the medical director for review.Appropriate letter language and coding (denials, deferrals, modifications).Appropriate selection of the preferred and contracted providers.Proper identification of eligibility and health plan benefits.Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out.Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.Meets or exceeds production and quality metrics.Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g., case management, engagement team, and disease management).Maintains and keeps in total confidence all files, documents, and records that pertain to the business operations.Performs other duties as assigned.Education & Experience Requirements:CA LVN license required. CA RN license preferred.Bachelor's or Master's degree in Social Work, behavioral or mental health, nursing, or other related health field preferred.3 to 5 years of acute care experience preferred.Two (2) years managed care experience in UM/CM Department preferred.Skills & Abilities Requirements:Knowledge of CMS, State Regulations, URAC, and NCQA guidelines preferred.ICD-9 and CPT coding experience a plus.Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel, and experience working in a health plan medical management documentation system a plus.Experience in EZ-CAP preferred.Medical Terminology preferred.#J-18808-Ljbffr
