Utilization Review Nurse RN

3 weeks ago

dubai, United Arab Emirates ClickJobs.io Full time
Coordinates and reviews all medical records, as assigned to caseloadActively participates in Case Management and Treatment Team meetingsServes as on-going educator to all departmentsResponsible 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 reportingAble 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 determinationIdentification of referrals to the medical director for reviewAppropriate letter language and coding (denials, deferrals, modifications)Appropriate selection of the preferred and contracted providersProper identification of eligibility and health plan benefitsProper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent outResponsible 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 preferred3 to 5 years of acute care experience preferred.Two (2) years managed care experience in UM/CM Department, preferredSKILLS & ABILITIES REQUIREMENTS:Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.ICD-9 and CPT coding experience a plusExperienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus Disclaimer: Drjobs.ae
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