Nurse, Concurrent Review

Job Description

• Performs concurrent inpatient utilization review using Inter Qual criteria to determine if the request meets medical necessity criteria, including:
• Admission reviews
• Continued stay reviews
• Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)
• Related follow-up activities and documentation updates
• Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions
• Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions
• Facilitates resolution of escalated cases that may require special handling
• Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines
• Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review time frames
• Maintains written documentation according to Health Help’s documentation policy
• Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies Inter Qual level-of-care criteria and applicable Health Help or client medical policies to inpatient review determinations
• Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs
• Complies with URAC & NCQA standards or other requisite regulating bodies
• Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management
• Keeps current with regulation changes as provided by Compliance Department and Nursing Management
• Functions as subject matter expert to support Compliance Department initiatives and updates
• Collects and enters confidential information ensuring the highest level of confidentiality in all areas
• Performs clinical intake and reviews cases according to the policies and procedures of Health Help for markets and cases requiring expedited turnaround times
• Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review time frames
• Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines
• Appropriately identifies and refers quality issues to UM Leadership
• Collaborates with client personnel to resolve customer concerns
• Provides quality customer service through interaction with providers, administrative staff, and others
• Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others
• Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy
• Participates in the Health Help Quality Management Program, as required
• Performs other related duties and projects as assigned to meet business needs

• RN graduate from an accredited school of nursing (BSN preferred)
• Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
• Two (2) years of experience in an acute care setting, required
• Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
• Experience with Inter Qual or similar evidence-based clinical decision support criteria, preferred
• Willingness to complete and maintain Inter Qual certification and ongoing competency requirements
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
• Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
• Knowledge of insurance terminology
• Experience working with state and federal regulatory and compliance standards, preferred
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
• Good organizational and time management skills
• Excellent written and verbal communication skills
• Abilit…