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Registered Nurse for Utilization Management
3 months ago
Position Overview:
As a Clinical Utilization Review Nurse, you will play a crucial role in ensuring that patient care meets established standards and guidelines. Your expertise will be vital in the assessment and coordination of medical records for a designated caseload.
Key Responsibilities:
- Review and coordinate all assigned medical records to ensure compliance with treatment criteria.
- Engage actively in Case Management and Treatment Team meetings to enhance patient care.
- Provide ongoing education to various departments to promote best practices.
- Evaluate patient charts to determine eligibility for admission and continued treatment, while gathering necessary clinical and fiscal information.
- Work independently, utilizing sound judgment in decision-making processes.
- Possess a comprehensive understanding of Federal, State, and intermediary guidelines related to inpatient care and lower levels of treatment.
- Facilitate discharge referrals as requested by clinical staff and families.
- Ensure timely and accurate referral determinations.
- Identify and refer cases to the medical director for further review.
- Utilize appropriate language and coding for letters regarding denials, deferrals, and modifications.
- Select preferred and contracted providers appropriately.
- Accurately identify eligibility and health plan benefits.
- Implement proper coding to manage record routing and determination notices.
- Collaborate closely with supervisors to address compliance issues and delays.
- Meet or exceed production and quality metrics consistently.
- Work directly with healthcare providers and Medical Directors to ensure quality service delivery.
- Identify opportunities for clinical program enhancements and refer members to relevant healthcare programs.
- Maintain confidentiality of all business operations files and records.
- Perform additional duties as assigned.
Education & Experience Requirements:
- California LVN license required; CA RN license preferred.
- Bachelor's or Master's degree in Social Work, behavioral health, nursing, or a related field preferred.
- 3 to 5 years of experience in acute care preferred.
- Two years of managed care experience in Utilization Management/Case Management preferred.
Skills & Abilities Requirements:
- Familiarity with CMS, State Regulations, URAC, and NCQA guidelines preferred.
- Experience with ICD-9 and CPT coding is a plus.
- Proficient in Microsoft Word, Outlook, Excel, and experience with health plan medical management documentation systems preferred.
- Experience with EZ-CAP is advantageous.
- Knowledge of medical terminology is preferred.
