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Review Nurse
2 months ago
Position Summary:
The role of the Nurse Reviewer is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests as well as acute inpatient admission. The Nurse Reviewer will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, Nurse Reviewer will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed. Work in collaboration with the Regional Medical Director to thoroughly review member referral history and anticipated needs in an effort to avoid admission. Responsible for identifying possible TOC cases for new members with high cost diagnosis. The Nurse Reviewer will be responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode as well as prior authorizations (particularly those with facility components). Identifying the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care.
Essential Duties and Responsibilities include the following:
- Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
- Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
- Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
- Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
- When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
- Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
- Maintain regulatory Turnaround Time Standards per regulatory guidelines.
- Document accurately and completely all necessary information in authorization notes.
- Approve those approvable requests as indicated based on protocols.
- Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
- Understand all applicable capitation contracts and how they apply to review duties.
- For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
- When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
- Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
- Participates in service recovery through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
- Identifies network needs and report to management for potential contracting opportunities.
- All other duties as directed by management.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an at-will position and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
- Employer-paid comprehensive medical, pharmacy, and dental for employees
- Vision insurance
- Zero co-payments for employed physician office visits
- Flexible Spending Account (FSA)
- Employer-Paid Life Insurance
- Employee Assistance Program (EAP)
- Behavioral Health Services
- 401k Retirement Savings Plan
- Income Protection Insurance
- Vacation Time
- Company celebrations
- Employee Assistance Program
- Employee Referral Bonus
- Tuition Reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
Requirements
Education and / or Experience:
- Graduate from an accredited Registered Nursing Program or Licensed Vocational Nursing Program.
- Current California Licenses
- Minimum of 1 year acute experience
- Knowledge of Healthcare and Managed Care preferred.
- Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
- Knowledgeable with the pre authorization process and workflow, with prior authorization experience preferred.
- Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
- Ability to deal with responsibility with confidential matters
- Ability to work in a multi-task, fast-paced, high-stress environment.
