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Lead Nurse in Utilization Review
2 months ago
Position Overview
The Senior Utilization Management Nurse plays a crucial role in evaluating inpatient admissions for our members, ensuring adherence to established guidelines for recognized care standards. Reporting directly to the Utilization Management Nurse Manager, this position involves a thorough review of clinical data from assigned inpatient facilities to assess medical necessity for admissions. Additionally, the role encompasses responsibilities related to discharge planning and facilitating transfers when higher levels of care or out-of-network admissions are required.
Key Responsibilities
In this capacity, you will be expected to:
- Conduct prospective, concurrent, and retrospective utilization assessments, along with first-level approval determinations for members, utilizing 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, coding accuracy, compliance with medical policies, and adherence to contractual obligations.
- Oversee discharge planning processes, ensuring that they align with the member's needs and acuity, while identifying post-acute requirements, including levels of care and necessary durable medical equipment.
- Prepare and present cases to the Medical Director for oversight and necessity evaluations, communicating decisions to providers and members in accordance with regulatory and accreditation standards.
- Develop and review documentation and correspondence that reflects member-centered determinations, ensuring compliance with regulatory and accreditation requirements while identifying potential quality of care issues.
- Collaborate with Case Management for any acute inpatient needs that may impact discharge.
- Participate in staff meetings, clinical rounds, and weekly huddles to foster team communication and collaboration.
- Maintain quality and productivity metrics for all casework to ensure high standards of service.
- Provide mentorship and support to new team members.
- Ensure a HIPAA-compliant workspace, particularly in a telework setting.
