UTILIZATION REVIEW NURSE

4 weeks ago

Corona CA USA, United States KPC Global MSO Full time
Victor Valley Global Medical Center

Victorville, CA

  • Coordinates and reviews all medical records, as assigned to caseload

  • Actively participates in Case Management and Treatment Team meetings
  • Serves as on-going educator to all departments
  • Responsible 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 reporting
  • Able 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 determination
  • Identification of referrals to the medical director for review
  • Appropriate letter language and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
  • Responsible 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 preferred
  • 3 to 5 years of acute care experience preferred.
  • Two (2) years managed care experience in UM/CM Department, preferred

SKILLS & ABILITIES REQUIREMENTS:
  • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
  • ICD-9 and CPT coding experience a plus
  • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
  • Experience in EZ-CAP preferred
  • Medical Terminology preferred

The posted pay scale represents the range the Company reasonably expects to pay candidates for this position. The actual wage for this position may depend on factors such as experience and education, specific skills and abilities, alignment with similar internal candidates, marketplace factors, an applicable collective bargaining agreement, and Company business practices.

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