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Utilization Review RN
4 months ago
ABOUT US:
Hines is a nationwide, independent leader in personalized managed health care, focused on what's important to you—comprehensive services with the program excellence and cost containment that you demand. Hines & Associates, Inc.'s reputation as an industry leader is founded on over three decades of innovative and professional health care excellence. Serving all aspects of the industry, Hines is committed to conserving health care dollars while ensuring quality care through effective programs and personalized service.
WHAT WE OFFER:
- Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, and company paid life insurance.
- 401k plan with company match, fully vested after 1 year.
- Paid holidays and time off.
- Work-life balance.
- Remote/hybrid setting.
ROLE DESCRIPTION:
This individual will utilize clinical knowledge and communication skills to obtain patient specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement. This individual will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with the health benefit plan, disability, workers compensation regulations and state and federal regulations. If these conditions do not appear to be met, this individual will defer decision to a second level reviewer. This individual interfaces with case managers and disease management nurses on active cases involved in other Hines' programs.
This is a Monday through Friday position, 9:30 AM to 6:00 PM.*
RESPONSIBILITIES AND PERFORMANCE
- Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to the clinical areas addressed in most initial clinical reviews. .
- Demonstrates ability to assess a patient's current medical status, including complications and untoward events, which may require additional intervention. Provides certification of medical, disability and workers compensation cases.
- Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required.
- Evaluates appropriateness of current plan of care.
- Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner.
- Maintains knowledge of current advances and trends in medical care.
- Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards.
- Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.
- Performs onsite evaluations as needed or requested.
- Additional responsibilities as assigned.
COMMUNICATION:
- Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner.
- Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.
- Provides written documentation concerning the clinical information obtained regarding the patient's status, benefit and claim concerns, and validation of criteria.
- Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice.
PERSONAL AND PROFESSIONAL:
- Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.
- Creative and assertive.
- All First Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.
PM21
Requirements:
QUALIFICATIONS:
- Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed. For mental health/substance abuse, licensed medical professional with an unrestricted license in the state or in a state that has licensure reciprocation with the state of the office location the employee is working in may perform first level reviews. Accepted licensure includes but is not limited to RN, LMSW, LMHC.
- Successful completion of UR nurse orientation program.
- Minimum of 3 years recent acute clinical practice required, 5 years preferred.
- Managed care, disability or workers compensation experience helpful but not mandatory.
- Customer service oriented.
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