Health Nurse - Utilization Review

Job Description

Position Title Health Nurse – Utilization Review Nurse

Reports To VP, Clinical Program Strategy and Integration

Department Health and Quality Management

Position Summary A Utilization Review Nurse (aka Health Nurse) at Alterwood Health is compassionate and resourceful in bringing positive change to members’ health. Health Nurses are responsible for reviewing provider requests, including medical records for outpatient medical procedures/services and durable medical equipment (DME), and to determine the medical necessity for such services. Health Nurse will collaborate with their counterparts in Case Management to ensure the safe transition of members from the inpatient to the outpatient setting.

Essential Duties and Responsibilities

• Research and apply national care guidelines such as Medicare National or Local Coverage Determinations, MCG, or InterQual to concurrent and preservice prior authorization (PA) requests.

• Process PA requests in a timeline fashion according to Medicare requirements.
• Collaborate with medical director and other specialists in the final disposition of certain PA requests.
• Provides support and facilitates arrangements for transitional of care activities and promotes continuity of care for members’ safe admissions, transfers, and discharges from hospital to skilled nursing and/or to home.
• Maintains collaborative working relationships with members’ providers, the appropriate state agencies, delegated vendors, and community providers/facilities.
• May perform duties telephonically as well as conducting on-site visits, if needed.
• Prepares, completes, and maintains clinical documentation in clinical systems through written case records/notes and performs case follow-up and closer, and performs other administrative tasks as required and in accordance with best practices and Medicare/Federal guidelines.

• Perform any other job-related instructions, as requested.

Education, Experience and Qualifications

• Licensed as a registered nurse or licensed practical nurse with the applicable state board of nursing license.
• At least two (2) years of clinical practice experience as a nurse working in a hospital or outpatient setting.

• At least one (1) year experience as a Utilization Review nurse at a health plan or healthcare setting.
• A working knowledge of Medicare program requirements.
• Current Certified Utilization Review or Utilization Management certification preferred.

Knowledge, Skills and Abilities

• Excellent communication skills, including writing, critical-thinking, and the ability to work with others in a collaborative fashion.
• Good computer skills (demonstrated use of Microsoft products, including Outlook, Excel, Word, and latest web-browsers) and overall computer use literacy.

• Ability to consume patients’ clinical/medical records and apply the information to national care guidelines such as Medicare National or Local Coverage Determinations, MCG, or InterQual.

• Working knowledge of health insurance and the clinical activities supporting members.

Job Type: Full-time

Pay: $75,000.00 - $95,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work Location: In person