Utilization Review Nurse

4 days ago

Portland, Maine, United States Martins Point Health Care Full time

At Martins Point Health Care, we're committed to transforming our healthcare system while creating a healthier community.

As a Utilization Review Nurse, you'll be part of a team that ensures high-quality, cost-efficient medical outcomes for our enrollees.

This role involves reviewing prior authorization requests, notifications of emergent hospital admissions, and inpatient concurrent reviews to establish discharge plans and coordinate transitions of care.

You'll use governmental policies and clinical guidelines to guide medical necessity reviews and apply effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

  • Ensure members receive the appropriate level of care
  • Promote cost-effective medical outcomes
  • Prevent hospitalization and readmissions when appropriate
  • Promote decreased lengths of hospital stays when appropriate
  • Provide continuity of care

Key Responsibilities:

Review prior authorization requests, concurrent reviews, and retrospective reviews for medical necessity, referring to the Medical Director as needed.

Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.

Manage medical claims disputes, records, and authorizations for billing, coding, and compliance or reimbursement-related issues.

Collaborate with team members, Medical Directors, healthcare providers, and members to promote effective utilization of resources.

Coordinate referrals to Care Management as appropriate.

Manage healthcare within benefits structures per line of business and perform functions within compliance, contractual, and accreditation regulations.

Maintain knowledge of applicable regulatory guidelines.

Complete all documentation of reviews and decisions in appropriate systems, according to process and compliance requirements, and within timeliness standards.

Participate as a member of an interdisciplinary team in the Health Management Department.

May be responsible for maintaining a caseload for concurrent cases or assisting in caseload coverage for the team.

Act as a liaison to ensure members receive the appropriate level of care at the appropriate place and time.

Mentor new staff into the case management role as assigned.

Assume extra duties as assigned based on business needs.

Participate in committees, work groups, team rounds, and/or projects as designated.

Attend ongoing training and continuing education to maintain professional competency.

Assist in creating and updating department policies and procedures.

Participate in quality initiatives and process improvements that reinforce best practice medical management programming and offerings.

Requirements:

Unrestricted state license as a Registered Nurse required; BSN preferred.

3+ years of clinical nursing experience.

Utilization management experience in a managed care or hospital environment required.

Certification in managed care nursing or care management desired (CMCN or CCM).

Skills and Knowledge:

Demonstrate an understanding of and alignment with Martins Point Values.

Maintain current licensure and practice within the scope of license for the current state of residence.

Maintain contemporary knowledge of evidence-based guidelines and apply them consistently and appropriately.

Ability to analyze data metrics, outcomes, and trends.

Excellent interpersonal, verbal, and written communication skills.

Critical Thinking:

Ability to identify root causes and understand coordination of medical and clinical information.

Ability to prioritize time and tasks efficiently and effectively.

Ability to manage multiple demands.

Ability to function independently.

Computer proficiency in Microsoft Office products, including Word, Excel, and Outlook.

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