Um Nurse Reviewer, Outpatient

Summary
Perform outpatient utilization review activities to determine the efficiency, effectiveness, and quality of health services. Serve as liaison between ordering and service providers and the Health Plan. Make medical determination decisions within defined protocols based on review of the service requests, clinical and non-clinical data, member eligibility, and benefit levels in accordance with contract and policy guidelines. Prepare letters to providers and members to convey approval or denial of requested services, identify and report on specific cases, and provide information regarding utilization management requirements and operational procedures to members, providers, and facilities. Communicate with the Medical Director regarding clinical questions and decision-making.
Responsibilities

• Conduct prospective, concurrent, and retrospective utilization review for outpatient services using medical necessity guidelines.
• Confirm payer authorization and communicate with payers in collaboration with insurance verification, as necessary.
• Performs concurrent reviews for patients to ensure that services are medically justified and are documented in patient's medical records.
• Ensure Utilization Management policy/processes are followed for those patients who do not meet criteria for ordered status.
• Discuss issues related to the plan of care, medical necessity, and payer communication.
• Refer to the standard workflow for cases that do not meet established guidelines and escalate appropriately.
• Perform first-level reviews to pre-certify elective services, procedures and tests utilizing established policies and protocols, benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.
• Work collaboratively with healthcare providers to assure appropriate utilization of services and care transition.
• Obtain clinical, functional, and psychosocial information from the medical records in a collaborative effort with health care professionals and the patient to determine medical necessity and benefit eligibility.
• Issue regulatory and other letters according to the department policies and procedures.
• Clarifies policies/procedures and consumer benefits as needed. Authorize services, coordinate care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed (collaboration with discharge planning)
• Refer all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case.
• Review physician reviewers’ determinations for appropriateness and completeness
• Communicate determinations to providers and consumers telephonically and in writing, adhering to corporate/department policy and regulatory guidelines.
• Other duties as assigned.

Knowledge, Skills, and Abilities

• Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
• Strong customer service orientation and aptitude.
• Critical thinking skills: the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Ability to communicate, verbally and in writing, complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Computers and Technology

• Applicable Microsoft Office Applications
• Experience with windows-based computer programs and ability to use computer for data analysis and data display required.
• Prefer experience with Medical Management platforms used to document care coordination services.

Certificates, Licenses and Registration

• Active Registered Nurse (RN) License within state of residence
• Certification in Case Management preferred.
• All Certifications and Licenses required for this job must be kept current as a condition of continued employment.

Education & Experience

• Associate degree (Required) bachelor’s degree preferred.
• Completion of an accredited nursing education program
• Three years clinical experience
• Two years of experience in utilization management or review
• Medicaid and Medicare Managed Care experience preferred.

Salary:44k-48k

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