Utilization Review Nurse Manaer

2 weeks ago

Chestnut Hill MA United States Arrow Mutual Liability Insurance Full time

Arrow Mutual Liability Insurance is seeking a talented individual for the position of UR Nurse Manager/UR nurse to determine the quality of care provided to injured workers including whether the medical services/procedures are appropriate and effective, performing Prospective, Concurrent and Retrospective reviews. To maintain our UR Department in regards to MA regulations per 452 CMR 6.00. This is a full-time position @ 37.5 hours, hybrid.



Objectives and Responsibilities:

·       Provides UR on all files via analysis of medical data with full certification review and determination supported by documented medical treatment guidelines and protocols

·       Conducts prospective, concurrent and retrospective review to certify medical necessity and appropriateness of requested services, i.e: admission, procedure or treatment, length of stay, frequency or duration of services.

·       Timely communication of decisions, verbal and written according to MA policies and procedures, state regulatory and mandated protocols

·       Review complex WC medical treatment requests to ensure accordance with evidence based medical treatment guidelines which are generally recognized by national medical community and are scientifically based.

·       Refers treatment requests, which do not meet guidelines, to Medical Director and/or for peer review and determination

·       Maintains UR/QA program according to the DIA/OHP criteria

·       Quarterly meetings with Medical Director to review UR/QA, include reviewing any complaints received, audit results, updates to UR program.

·       Maintains Program, including updates to OHP and re-applications as scheduled

·       Maintains written and verbal communication between Medical Director, medical provider(s), claim managers, attorney(s), insured and claimant

·       Routinely contacts providers to clarify treatment requests, examination findings, as well as obtain additional medical information as needed

·       Maintain clear, concise and accurate documentation of requested medical treatments to include clinical findings, treatment guidelines and determination

·       Develops and maintains all forms/letters used in the Utilization Review Program

·       Act as medical resource in regards to UR to claim support, claim manager

·       Must identify the necessity of the review process and communicate any specific issues of concern to claim manager and/or medical provider

·       Maintains contact with Medical Director

·       Communicates effectively with individuals outside the company including insured, medical providers and vendors


Qualifications

·       Valid Massachusetts RN license with minimum 5 years nursing experience

·       Must keep license and any certification status valid, maintain CEU’s

·       Able to work under expedited and adherence to regulatory timelines

·       Technical skills; knowledge of current recognized evidence-based guidelines, office operations, workflow analysis and current technologies in data entry, file management, telecommunications.

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