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Advanced Utilization Management Nurse
2 months ago
Position Overview
The Senior Utilization Management Nurse plays a crucial role in assessing inpatient admissions for our members, ensuring adherence to established care guidelines. Reporting to the Utilization Management Nurse Manager, this position involves evaluating clinical data from various facilities to ascertain the medical necessity of admissions. Additionally, the role encompasses responsibilities related to discharge planning and facilitating transfers when higher levels of care or out-of-network services are required.
Key Responsibilities
In this capacity, you will be expected to:
- Conduct thorough prospective, concurrent, and retrospective utilization assessments, providing first-level approval determinations based on evidence-based guidelines and recognized clinical criteria across different business lines, 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.
- Oversee discharge planning that aligns with the member's clinical needs and severity, identifying post-acute requirements such as levels of care, durable medical equipment, and other necessary services to facilitate effective discharge.
- Prepare and present cases to the Medical Director for oversight and necessity evaluations, ensuring clear communication of determinations to providers and members in accordance with regulatory and accreditation standards.
- Create and review member-focused documentation and correspondence that reflects determinations while complying with regulatory and accreditation requirements, identifying potential quality of care concerns and intervening as clinically appropriate.
- Collaborate with Case Management for acute inpatient needs impacting discharge processes.
- Participate in staff meetings, clinical rounds, and weekly team huddles.
- Maintain quality and productivity metrics for all casework undertaken.
- Provide mentorship and support to new team members.
- Ensure a HIPAA-compliant workspace, particularly in a telework setting.
