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Utilization Review Nurse-SelectHealth
2 months ago
Duties:
"Analyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria
while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification
standards.
Implements utilization management processes and coordinate medical services with other SelectHealth and Intermountain departments, as
well as local, state and federal programs (Medicare, Medicaid, etc.)
Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax,
electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization.
Proactively and collaboratively interfaces with physicians, internal staff, members and members' families to assist in expediting appropriate
discharge, obtain authorizations, and direct toward medically necessary care. Resolves member, family/caregiver assistance requests.
Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home
Health agency services. Performs retrospective reviews as needed for services rendered without an authorization.
Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of
care. Coordinates with specialty vendors or providers for post-acute care needs.
Contributes to the development and maintenance of policies and procedures to ensure regulatory compliance, identifying new policies and
procedures that are required. Complies with all standards pertaining to accreditation (NCQA or other regulatory bodies).
Demonstrates a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to
effectively identify opportunities and coordinate referrals for care management intervention.
Perform all required documentation and entry into utilization management operating system for authorization and determination.
Contribute to the effectiveness and efficiency of the department. Participate in the documentation of the utilization management program,
work plan, and annual evaluation including necessary submission to accreditation or other regulatory bodies.
Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member
satisfaction.
Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards.
Consistently adhere to department productivity and performance expectations.
Consistently demonstrates an attitude of customer service excellence to both internal and external customers."
Skills:
"Preferred Qualifications
Current working knowledge of Medicare, Medicaid and Commercial insurance.
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Current working knowledge of utilization management and case management techniques.
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Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
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Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment."
