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Clinical Utilization Review Specialist
2 months ago
Job Title: Utilization Review Nurse
Position Type: Part-Time (Every other weekend - Saturday and Sunday, totaling 30 hours per month)
Training Requirement: Candidates must be available M-F during typical business hours for a 4-week training period.
Job Overview: The Utilization Review Nurse plays a crucial role in assessing the clinical status of members by reviewing medical documentation to ascertain the necessity of healthcare services. This position necessitates direct communication with healthcare providers to gather additional clinical data when required. The nurse has the authority to approve medically essential services based on their evaluations but must escalate cases that do not satisfy the established criteria to the Medical Director. This role is pivotal in ensuring compliance with regulations and serves as a patient advocate, assisting members in navigating the complexities of the healthcare system.
Key Responsibilities:
- Utilize advanced medical knowledge and critical thinking skills to evaluate the appropriateness of care using defined resources and guidelines.
- Employ InterQual criteria and Medical Policy to determine the necessity for inpatient admissions, procedures, and ancillary services.
- Engage with providers to review treatment strategies and clarify medical requirements.
- Analyze and confirm treatment plans for requested services, inpatient admissions, or ongoing stays.
- Refer cases that do not meet established criteria to the Medical Director for further assessment.
- Identify members requiring discharge planning early and collaborate with case management personnel or physicians to ensure appropriate discharge arrangements.
- Monitor potential utilization challenges or trends and offer recommendations for enhancements.
- Refer cases to the Quality Management Department and/or Care Management and Coordination Manager as necessary.
- Ensure that requests align with members' benefit plans and adhere to state, federal, and accreditation standards.
- Meet regulatory turnaround times and departmental productivity objectives.
- Maintain precise and timely data entry in the system.
Qualifications:
Education:
- Active PA Licensed RN
- BSN preferred
Experience:
- A minimum of three (3) years of acute care clinical experience in a hospital or healthcare environment.
- Previous experience in discharge planning and/or utilization management is advantageous.
- Experience in medical management/precertification is preferred.
Knowledge & Skills:
- Outstanding communication, problem-solving, and interpersonal abilities.
- Strong capability to prioritize tasks and achieve outcomes.
- Collaborative team player with the ability to foster team spirit and interdepartmental relationships.
- Open-minded and adaptable to new ideas and methodologies.
- Respectful of workforce diversity and colleagues.
- Excellent organizational and prioritization skills.
- Effective time management capabilities.
- Informed about current trends in medical practice.
- Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs, with the capacity to learn new systems.
