Utilization Review Registered Nurse

SUMMARY:

The Authorization Nurse will oversee the processing of assigned authorizations for participant care, supplies, and other related needs. This will include but not be limited to primary responsibility for Emergency Room and Hospital Admission authorizations as well as oversight of accurate completion of all other types in conjunction with clinical and supportive staff.

SPECIFIC DUTIES AND FUNCTIONS:

Enter authorizations for participants seen in Emergency Departments and/or Admitted to the Hospital, including Observation stays; complete authorization to include all required information (i.e. discharge date, diagnosis, discharge location).Coordinate authorization information for all participant care needs with interdisciplinary team (IDT) members ensuring completeness of all required  tandem with Authorization Coordinator, monitor all participant authorizations in EMR for accuracy and correct information.

Assess need and provide education to IDT staff regarding authorization processing and management to improve compliance where required.

Recommend workflow modifications/changes to improve PACE Southeast MI authorization management in terms of both efficiency and quality.

Audit EMR (currently Tru Chart) for authorization status, notifying individuals and leadership of any trends or issues relating to timeliness, error rates, or similar quality issues.

Assign specific tasks to support audit needs and action plans to Authorization Coordinator.

Present audit findings to key Leadership Team members on a regular basis plus as requested, participating as a member of the PACE Southeast MI Quality Improvement Team.

Other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:

Registered Nurse in State of MI with unencumbered license, BSN preferred;

Minimum 2 years’ experience in a managed care environment, preferably in a utilization related role;

Must have one year of experience with a frail, elderly populationWORK ENVIRONMENT:

Professional office environment

Occasional interaction with participants with risk of exposure to communicable diseases
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