Utilization Management Nurse Reviewer

MAJOR RESPONSIBILITIES

·         Has a working knowledge of regulations and accreditation requirements by state and specific markets and applies appropriate LCD/NCD, HealthHelp or Client’s medical policy guidelines

·         Performs utilization review of cases to determine if the request meets criteria

·         Facilitates resolution of escalated cases that may require special handling

·         Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times

·         Collects and enters confidential information ensuring the highest level of confidentiality in all areas

·         Refers cases to a Physician Reviewer or Specialty Medical Director per guidelines

·         Collaborates with client personnel to resolve customers concerns

·         Appropriately identifies and refers quality issues to UM Leadership

·         Assist Physician Reviewer Medical Directors as necessary to ensure timeframe compliance

·         Maintains written documentation according to HealthHelp’s documentation policy

·         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

·         Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs

·         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 to the company’s vision, mission, and strategy

·         Participates in the HealthHelp Quality Management Program as required

·         Adheres to both URAC & NCQA standards pertinent to their job description

·         Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meets critical deadlines

·         Capable of communicating clinical concepts to providers and staff based on guidelines

·         Performs other related duties and projects as assigned to meet business needs

QUALIFICATIONS

·         RN, LPN/LVN graduate from an accredited school of nursing

·         Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.

·         Minimum of Three (3) years of experience in an acute care setting preferred

·         Minimum of 2 years previous utilization review experience in a managed care setting required

·         Familiar with State and Federal standards/requirements

·         Working knowledge of NCDs, LCDs, MCG, and InterQual

·         Knowledge of insurance terminology

·         Experience working with state and federal regulatory and compliance standards, preferred

·         Computer proficiency demonstrated by passing an “eSkills” exam

·         Good organizational and time management skills required

·         Excellent written and verbal communication skills

·         Ability to utilize critical thinking skills

·         Highly motivated, self-starter who can work efficiently and independently, or as a team member

·         Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint)

All your information will be kept confidential according to EEO guidelines.