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Senior Nurse for Utilization Management
2 months ago
Position Overview
The Senior Utilization Management Nurse plays a crucial role in evaluating inpatient care for our members, ensuring adherence to established guidelines for recognized care standards. Reporting to the Nurse Manager of Utilization Management, this position involves reviewing clinical data from assigned inpatient facilities to assess the medical necessity of admissions. Additionally, the role encompasses responsibilities related to discharge planning and coordinating transfers for higher levels of care or out-of-network admissions.
Key Responsibilities
In this capacity, you will:
- Conduct prospective, concurrent, and retrospective reviews of utilization, making first-level determinations for members based on evidence-based guidelines and nationally recognized clinical criteria across various lines of business, including Medicare and FEP.
- Perform clinical evaluations of claims to ensure medical necessity, accuracy in coding, compliance with medical policies, and adherence to contractual obligations.
- Facilitate discharge planning that aligns with the members' needs and acuity, determining necessary post-acute care, durable medical equipment, and other services to promote quality and cost-effective discharge processes.
- Prepare and present cases to the Medical Director for oversight and necessity determinations, ensuring communication of these determinations to providers and members in accordance with regulatory and accreditation standards.
- Develop and review documentation and correspondence that reflects member-centered determinations, complying with regulatory and accreditation requirements while identifying potential quality of care issues and intervening as clinically appropriate.
- Collaborate with Case Management for acute inpatient needs impacting discharge.
- Participate in staff meetings, clinical rounds, and weekly huddles to ensure cohesive team operations.
- Maintain quality and productivity metrics for all casework to uphold organizational standards.
- Support and mentor new employees as they acclimate to the role.
- Ensure a HIPAA-compliant workspace, particularly in a telework setting.
