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Clinical Utilization Review Nurse
2 months ago
The Utilization Review Nurse is responsible for conducting both prospective and retrospective evaluations for post-acute care services. The primary objective of utilization management is to ensure that WellSky's population receives necessary medical services in the correct environment, with the right provider, and at the suitable level of care.
This role entails the prompt assessment of requests for post-acute services. Utilizing established clinical guidelines and coverage benefit limitations, the nurse will determine the appropriateness of the requested services.
Key Responsibilities:- Conduct initial prior authorization assessments for post-acute care services, applying guideline criteria for approval and consulting with Medical Directors when necessary for adverse determinations.
- Authorize post-acute care services in accordance with contractual agreements, health plan guidelines, and medical necessity criteria.
- Leverage knowledge of healthcare system resources to effectively assist physicians and patients.
- Complete Interrater Reliability Testing to ensure consistency in reviews and application of criteria.
- Make benefit determinations regarding appropriate levels of care using clinical guidelines.
- Facilitate benefits coordination and transitions across various care settings.
- Consult with Medical Directors for complex cases as needed.
- Utilize clinical expertise when engaging with internal and external Case Managers and Physicians.
- Adhere to all Standard Operating Procedures throughout the case management process.
- Gather clinical information to assess and expedite reviews as required.
- Participate in team meetings, educational discussions, and related activities.
- Maintain compliance with Federal, State, and accreditation standards.
- Identify opportunities for enhancing communication and processes.
- Engage in various special projects and undertake additional duties as assigned.
Required:
Active RN license and a minimum of 5 years of clinical nursing experience.
Preferred:
RN Compact License, experience in utilization review, case management, or managed care, familiarity with MCG/Interqual or other criteria-based applications, and a general understanding of managed care guidelines.
Graduation from an accredited nursing program is essential, along with at least 1-2 years of experience in utilization management, case management, or managed care regulations.
Proficiency in computer skills, including MS Office, MS Excel, and Clinical/Operational Software, is required.
Additional Expectations:- Willingness to work additional or irregular hours as necessary.
- Adherence to corporate and organizational security policies and procedures.
- Execution of other responsibilities as assigned.
At WellSky, we foster an environment where independent thinking and collaboration thrive, promoting innovation and inclusiveness. We are committed to making a difference in the healthcare landscape.
WellSky is an equal opportunity employer, providing opportunities to all individuals without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sexual orientation, gender identity, marital status, disability, or any other characteristic protected by law.
WellSky is proud to maintain a drug-free workplace.
