Registered Nurse
1 week ago
The Utilization Review Nurse performs prospective and retrospective reviews for post-acute care services. The purpose and goal of utilization management is to assure that Wellsky's population receives medically necessary services in the appropriate setting, with the appropriate provider, and at the appropriate level of care. This position is responsible for timely review of request for post-acute services and based on established clinical guidelines and/or coverage benefits limitations, determine appropriateness of requested services. The Utilization Review Nurse will comply with all standard operating procedures, and all departmental and organizational policies. They will meet and/or exceed minimum
benchmark established for the role. They will develop relationships with physicians, healthcare service providers, internal and external customers to help improve health outcomes for enrollees. They will apply clinical knowledge to work with facilities and providers for care coordination. They will access and consult with peer clinical reviewers, Medical Directors, and/or delegated clinical
reviewers to help ensure medically appropriate, quality, cost-effective care throughout the medical management process.
A day in the life
Primary Responsibilities:
* Perform initial prior authorization review of post-acute care services applying guideline criteria for approval and sending to Medical Directors if review is necessary for determining an adverse determination.
* Authorize post-acute care services in compliance with contractual agreements, health plan guidelines and medical necessity criteria.
* Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.
* Successfully complete the Interrater Reliability Testing to ensure consistency of review and application of criteria.
* Make benefit determinations about appropriate levels of care using clinical guidelines.
* Coordinate benefits and transitions between various areas of care
* Consult with the Medical Director as needed for complex cases.
* Apply clinical expertise when discussing case with internal and external Case Managers and Physicians.
* Follow all Standard Operating Procedures in end-to-end management of cases.
* Obtain clinical information to assess and expedite reviews as necessary.
* Participate in team meetings, education discussions and related activities.
* Maintain compliance with Federal, State and accreditation organizations.
* Identify opportunities for improved communication or processes.
* Works on a variety of special projects and assumes other duties as assigned.
Do you have what it takes?
Required Qualifications:
* Active RN license.
* 5+ years of clinical nursing experience.
Do you stand above the rest?
Preferred Qualifications:
* RN Compact License highly preferred.
* Experience in utilization review, case management and/or managed care.
* MCG/ Interqual or other criteria-based applications.
* General understanding of managed care guidelines and impact on services.
* Graduate of an accredited school of nursing.
* Minimum of 1-2 years of utilization management experience, case management, managed care regulations; or any combination of education and experience, which would provide an equivalent background required.
* Able to pass federal and state required criminal / abuse background checks and drug screen.
* Computer skills including but not limited to MS Office, MS Excel, and Clinical / Operational Software.
Additional job expectations applicable to this position include:
* Willingness to work additional or irregular hours as needed
* Working in accordance with corporate and organizational security policies and procedures
* Performing other responsibilities as assigned
WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference.
WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace.
Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.
Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:
* Excellent medical, dental, and vision benefits
* Mental health benefits through TelaDoc
* Prescription drug coverage
* Generous paid time off, plus 13 paid holidays
* Paid parental leave
* 100% vested 401(K) retirement plans
* Educational assistance up to $2500 per year
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