Clinical Utilization Review Nurse

3 days ago

Rockford, Illinois, United States Hines & Associates Inc Full time
About Hines & Associates Inc.

Hines & Associates Inc. is a nationwide, independent leader in personalized managed health care, focused on delivering comprehensive services with program excellence and cost containment. With over three decades of innovative and professional health care excellence, Hines has established a reputation as an industry leader.

What We Offer
  • Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, and company-paid life insurance.
  • 401k plan with company match, fully vested after 1 year.
  • No weekends and nights.
  • Paid Holidays.
  • Work-life balance.
  • Remote/hybrid setting (once trained).
Role Description

This individual will utilize clinical knowledge and communication skills to obtain patient-specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement.

This individual will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with the health benefit plan, disability, workers compensation regulations, and state and federal regulations. If these conditions do not appear to be met, this individual will defer decision to a second-level reviewer.

This individual interfaces with case managers and disease management nurses on active cases involved in other Hines' programs.

Responsibilities and Performance
  • Completes first-level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review.
  • Demonstrates ability to assess a patient's current medical status, including complications and untoward events, which may require additional intervention.
  • Demonstrates a thorough understanding of criteria sets and their limitations, including when a second-level review is required.
  • Evaluates appropriateness of current plan of care.
  • Assesses aftercare needs, implements discharge planning, and/or case management referral in a timely manner.
  • Maintains knowledge of current advances and trends in medical care.
  • Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions.
  • Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.
  • Performs onsite evaluations as needed or requested.
  • Additional responsibilities as assigned.
Communication
  • Communicates with hospital staff, physicians, other providers, and Hines customer contacts in a competent, calm, effective, and professional manner.
  • Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.
  • Provides written documentation concerning the clinical information obtained regarding the patient's status, benefit, and claim concerns, and validation of criteria.
  • Communicates knowledge of policies and procedures, URAC guidelines, disability, and workers compensation regulations, state and federal requirements, and standards of practice.
Personal and Professional
  • Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.
  • Creative and assertive.
  • All First-Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.

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