Utilization Management Reviewer

Summary / Objective:

This Registered Nurse position performs functions related to both Utilization Review & Care Management for a delegated managed care population. The nurse performs reviews for enrollees across the service continuum (pre-certification / authorization, concurrent and retrospective reviews) utilizing guidelines for decision making such as InterQual, NCD, and LCD criteria to ensure the quality, quantity, timeliness and effectiveness of service. The nurse acts in a non-caregiver capacity by facilitating coordination and communication between all members of the health care team in the decision-making process to minimize fragmentation of the health care delivery system. This position is responsible for contributing to the standards of quality and service expected by both external and internal stakeholders, including ensuring accurate information flows to interdepartmental teams, proper documentation and adherence to standards related to case management activities.

Essential Functions:

• Exceed physician, provider and member expectations by providing professional and personalized service at all times.
• Is aware of and continually supports strategic plans that ensure company objectives and goals are obtained.
• Attend collaborative meetings with both internal and external healthcare team members to support management services for clients served.
• Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere.
• Assess clients for care management services after a referral has been made based on the admission screening and referrals for potential patient issues.
• Develop and manage a coordinated plan of care to meet client and/or family needs
• Assure that clients are placed on appropriate self-management plan and protocols, individualizes client care needs through consultation with the multidisciplinary team.
• Coordinates services to support the appropriate care needs to promote best client outcomes and efficient use of healthcare resources.
• Works with clients and providers to enhance the quality of client management and satisfaction.
• Performs appropriate assessments and develops client-directed care plans within health plan required timeframes and per NCQA standards.
• Assess need to involve medical director or primary care team when appropriate to assist with development of client-directed plan of care.
• Regularly reviews and updates care plans for continuity of care and facilitates plan modifications including barriers to goals.
• Coordinates with Non-Licensed Care Navigators to ensure appropriate follow-up with high-risk clients to address identified goals and barriers.
• Documents all interventions and telephone encounters with providers, members and vendors in accordance with established documentation standards.
• Provide comprehensive training for new employees.
• Continues own education by keeping his/her knowledge current and conducts independent research of commercial plan guidelines to strengthen general understanding of state and federal resources to support position responsibilities.
• Ensures compliance with departmental and PSW policies and procedures, with special emphasis on compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.
• Provides Transitional Care Management services post discharge from emergency room, acute inpatient, or post-acute inpatient stays.
• Follows Eric Coleman's Pillars of Transitional Care to support reduced risk of adverse events following discharge.
• Provides education on seeking medical attention early or using urgent care services when appropriate versus an emergency room.
• Follows the standards of care management services as outlined in the guideline manual updated no less than annually.
• Provides telephonic engagements to clients on worklist to meet standards of engagement to include both timing, frequency, and duration of engagements.
• Identifies, assesses and manages clients receiving services per established criteria. Coordinates activities with public agencies, social workers, hospital/nursing facility discharge planner, ancillary service providers
• Continues own education by keeping their knowledge current and conducts independent research of Medicare guidelines to strengthen general understanding of state and federal resources to support position responsibilities.
• Reviews requests as required, performs preadmission, and concurrent reviews for appropriateness of admission, continued stay, length of stay, utilization of resources, patient outcomes and discharge planning needs.

Includes acute patient hospital, post-acute Skilled Nursing, Long-Term Care, and Inpatient Rehab reviews for appropriateness of level of care requested.

• Use established criteria and policy/procedures to perform pre-admission, admission, and continued stay reviews on inpatient and skilled nursing cases in accordance with NCQA and CMS guidelines.
• Professionally communicate with members, health plan partners, or providers with verbal or written communication of decisions related to approval or denial of services.
• Identify at-risk members in need of case/disease management programs and complete appropriate referrals.
• Works with Interdisciplinary Team (IDT) to assist with delivery of well-coordinated high-quality health care, tracking and escalation of high dollar cases.
• Participate in department initiatives and projects focused on quality improvement.
• Participate in cross-training of clinical and non-clinical roles, as appropriate, to ensure understanding of processes driving compliance, turnaround times, and authorization workload tracking.
• Exceed expectations in professional and personalized service level to internal and external partners.
• Implement new policies, procedures and initiatives as assigned and ensure all areas are maintained in accordance with company policy, state, federal and plan regulatory mandates.
• Support technology implementations focused on opportunities to scale and automate components of the UM process to improve compliance tracking (e.g. fax software, authorization system upgrades, etc.)
• Collaborates with internal and external healthcare team members to achieve organizational IP, ED, SNF utilization, length-of-stay, and readmission goals.
• Build and leverage cross-functional collaborative relationships to support tracking of inter-related utilization, cost, and claims reconciliation initiatives.
• Promotes continuity of care and cost effectiveness through integrating functions of case management and utilization review to identify barriers to optimal patient care.
• Assess member physical, psychological and discharge planning needs through communication with appropriate care providers to coordinate care accordingly.
• Work with members and providers to enhance the quality of patient management and satisfaction.
• Support comprehensive training for new employees to ensure mastery of work product and clear expectations.

Knowledge/Skills/Abilities:

• Set a positive example by displaying a pleasant and approachable demeanor and always remaining friendly and courteous.
• Proactive team player, strong follow-through, quick decision-making and problem-solving abilities.
• Interpersonal skills, with the ability to build strong relationships at all levels.
• Strong verbal and written communication skills with customers, supervisors, and co-workers.
• Strong organizational, time management and prioritization skills:
• Self-starter. Ability to set priorities and keep to projected schedules.
• Excellent computer proficiency (MS Office – Word, Excel, Outlook) including being able to effectively maintain written and computer records in accordance with regulatory agencies.
• Familiarization and experience with Electronic Health Record systems.

Required Education and/or Work Experience:

• Three (3) years of full proficiency clinical experience.
• Minimum 1 year of experience in UM/UR.
• Verifiable experience or knowledge of a variety of clinical areas of medical treatment.
• Knowledge of hospital/patient care facilities, current practices, procedures, acceptable medical treatment and diagnoses.
• Knowledge and experience in providing care management and/or transitional care management services

Preferred Education and/or Work Experience:

• Bachelor's degree from accredited school of nursing.
• Certified Case Manager (CCM) or Health Utilization Management Certification (HUMC)
• Experience with health plan/HMO utilization review/management and/or case management experience.
• Knowledge of Interqual and/or Milliman Utilization Criteria.
• Experience working with Medicare Advantage/CMS.

Required Certificates, Licenses and Registrations:

• Registered Nursing license.
• Active unrestricted state license in State of Washington.

PSW does not typically hire new employees near the top of the salary range.

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Flexible spending account
• Health spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance