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Utilization Review Nurse
4 months ago
The Utilization Review Nurse determines the appropriateness of inpatient and outpatient services for patients who have been admitted into the hospital. This is accomplished by close evaluation of medical guidelines and benefit determination criteria. The Utilization Review Nurse coordinates with CCMC staff (e.g., Primary Care Provider, Clinic Case Manager) and external stakeholders (e.g., Health Plan Utilization Manager, and facility Utilization department) to ensure patient is receiving the appropriate level of care and timely discharge planning. Candidate will have experience with advocating alternate levels of care with providers, health plans, and utilization/case managers, all whilst preparing a transition of care that mitigates the risk of readmission.
Duties and Responsibilities:
- Perform initial and concurrent review of inpatient cases by leveraging knowledge and experience with evidenced-based criteria.
- Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services.
- Refers to the treatment plan for clinical reviews in accordance with established criteria in recommended compendia and or guidelines.
- Serves as a resource to provide education regarding payer policies and facilitates coordination of alternative treatment options.
- Builds strong relationships with preferred acute care providers and health plan stakeholders.
- Apply clinical expertise when discussing case with internal and external Case Managers, Utilization Managers, and Providers.
- Facilitates timely, appropriate care and effective discharge planning with the mindset to ensure seamless transition to the outpatient setting.
- Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the health plan utilization manager, facility utilization manager, and claims contestation department.
- Maintains knowledge regarding payer reimbursement policies and clinical guidelines.
- Responsible for identifying patients that will benefit from initiatives and programs including Case Management and Disease Management.
- Participate during intradisciplinary meetings and collaborate with all members of the healthcare team to detect and target high utilizers and clinically complex patients.
- Assist with development, implementation, education, evaluation, and revision of departmental standards related to Inpatient and Observation admissions.
- Effectively and efficiently complete clinical case summaries from a variety of medical record documentation for internal and external audiences, including for commercial payers and Medicare and Medicaid contractors.
- Performs other duties as assigned.
Qualifications / Education / Licenses:
- Graduate from an accredited school of nursing.
- Active Registered Nurse license in the state of Florida.
- 2 years of relevant health plan or hospital utilization management experience.
- Subject Matter Expert with evidence-based guidelines (MCG, InterQual Guidelines)
- Basic computer knowledge; Microsoft Office experience, sending e-faxes and email, document with electronic health records and/or authorization system.
At Clinical Care Medical Centers, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and employees without regard to race, color, religion, sex, pregnancy, national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, military and veteran status, and any other characteristic protected by applicable law. Clinical Care Medical Centers believes that diversity and inclusion among our employees is critical to our success as a company. We support an inclusive workplace where employees excel based on personal merit, qualifications, experience, ability, and job performance.
