UTILIZATION REVIEW NURSE

3 weeks ago


RI United States US Tech Solutions, Inc. Full time
 

Job Description:



· Participates in the development and ongoing implementation of QM Work Plan activities.



· Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives



 



 



Responsibilities:



· Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.



· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.



· Data gathering requires navigation through multiple system applications.



· Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.



· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.



· Responsible for the review and evaluation of clinical information and documentation.



· Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.



· Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).



· Independently coordinates the clinical resolution with internal/external clinician support as required.



· Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data



· Prepares and completes QM documents based on interpretation and application of business requirements



· Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements



· Assists in the development and implementation of QM projects and activities



· Accountable for completing and implementation of QM Work Plan Activities



 



Experience:



 



· 3+ years of experience as an RN



· 1+ years of inpatient hospital experience



· Registered Nurse in state of residence



· Must have prior authorization utilization experience



· Able to work in multiple IT platforms/systems



 



Skills:



· MUST HAVE MEDCOMPASS or ASSURECARE exp.



· MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.



· MUST HAVE UM experience, inpatient utilization management review.



· MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.



· MUST HAVE 6 months of Prior Authorization.



 



Education:



· Active and unrestricted RN licensure in state of residence



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