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Clinical Utilization Review Nurse
2 months ago
Clinical Utilization Review Nurse III
Under the direct oversight of the Utilization Review (UR) nursing supervisor, the UR Nurse III is responsible for conducting thorough evaluations of assessments, Individual Service Plans (ISPs), and pertinent documentation to assess long-term services and supports (LTSS) within Medicaid managed care. This role is essential in determining adherence to established policies, procedures, regulations, and the accuracy of needs assessments for Medicaid managed care LTSS.
The UR nurse employs a variety of assessment techniques, including record reviews and direct interviews with waiver members, to validate service requirements and the effectiveness of service delivery.
This position allows for a moderate degree of autonomy in exercising initiative and independent nursing judgment during evaluations.The UR Nurse III will handle intricate policy interpretations and validate or recommend clinical review decisions made by Medicaid managed care organizations (MCOs) and provider agencies.
Additionally, this role is accountable for precise and timely reporting.The UR Nurse III will collaborate effectively with MCOs and providers to ensure that interdependent functions are executed seamlessly.
Key Responsibilities:Maintains regular attendance in accordance with agency leave policies and performs additional duties as assigned.
Implements UR activities.Evaluates MCO policies and procedures, nursing practices, medical records, assessments including medical necessity/level of care (MN/LOC), and ISPs to ensure compliance with standards, accuracy of assessments, and quality of care.
Recommends enhancements based on review findings. 40% Generates routine and specialized data for program reports. (20%) Ensures timely and accurate reporting of program activities. 15%. Collaborates with internal divisions on program outcomes as necessary. 10% Interprets complex state and federal regulations related to the program. Performs other duties as assigned.15% Required Knowledge, Skills, and Abilities:
Knowledge of:
nursing methodologies and protocols; healthcare regulations, standards, and laws; medical diagnoses and procedures; recognized medical treatment programs; principles and practices of community health and nursing care; Medicaid and managed care guidelines; utilization management principles; and healthcare services for the elderly, disabled, and pediatric populations with special needs.
Skill in:
organizing tasks; patient care and treatment; effective written and verbal communication necessary for developing and reviewing unit policies, rules, and guidelines; and for consulting, teaching, and providing clear instructions and reports.
Ability to:
identify suitable nursing care and other healthcare services; prepare, maintain, and present reports; explain and interpret relevant health laws, rules, standards, and regulations; organize, coordinate, and assess nursing activities and public health service delivery; recognize patterns of medical necessity, treatment fraud, abuse, and neglect; proficiently use a personal computer, fax machine, copier, telephone conferencing tools, and components of the Microsoft Office suite and Outlook email; travel independently as required.
Ability to gather, compile, correlate, and analyze information; devise solutions to challenges; develop and assess policies and procedures; and prepare comprehensive reports.
