Utilization Review Nurse RN

4 months ago


Dubai, United Arab Emirates ClickJobs.io Full time

Victorville, CA

  • 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 in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request 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


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