Utilization Review Nurse Health Plans - Case Management

Description

Summary:

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse performs pre-admission, concurrent, and retrospective utilization management (UM) reviews and functions. They competently and accurately utilize approved screening criteria (Inter Qual/MCG/CMS Inpatient List). They manage a diverse workload in a fast-paced, regulatory environment and maintain current knowledge regarding commercial and government payors and guidelines related to UM.

The nurse communicates with internal and external clinical professionals, coordinates financial insurance care for patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates with other members of the health care team to align with the CHRISTUS mission.

• Meets expectations of the applicable OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Avoid complex or chronic conditions in coordination with transition of care, disease management support, or other identifiable needs for coordination of the member's health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to HIPAA to protect PHI and prevent unauthorized disclosure.
• Protect the confidentiality of data and intellectual property; ensure compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate medical necessity, appropriateness, and efficiency of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, referral to in-network providers, durable equipment usage, and telephonic follow-up for necessary care.
• Utilize the nursing process and critical thinking to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities; demonstrate cultural sensitivity and appropriateness.
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after-hours calls to meet business requirements as needed.

Education/Skills

• Graduate of an accredited school of vocational nursing or equivalent required
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred

Experience

• 3–5 years of nursing experience preferred
• Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
• General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

• LVN license in the state of employment or compact required
• RN license in state of employment or compact preferred

Work Schedule: 5 Days - 8 Hours

Work Type: Full Time