Outpatient Utilization Review Nurse (189495-955)

Description

Primary Function:

Responsible for the effective and sufficient prioritization of outpatient utilization of faxes and support of all utilization management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.

 

Responsibilities:

·           Performs all utilization review activities according to Health Services Policy and Procedures. Contacts providers as appropriate to obtain necessary information.

·           Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines.

·           Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines.

·           Refers cases to the Medical Director/Physician Advisor as appropriate.

·           Enters all information into the health plan’s computer documentation system ensuring complete and accurate information in a timely manner.

·           Notifies hospital and/or providers of all denials and generates denial letters when recommended by the Medical Director/Physician Advisor.

·           Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator.

·           Reviews selected claims and retrospective requests for certification and follow-up as necessary with the UM Manager or Medical Director.

·           Participates in education of providers regarding Health Services policies and procedures.

·           Identifies and refers cases to the case management or disease management department as appropriate.

·           Maintains strong working relations with internal and external customers. Presents all communication in a positive and professional approach.

·           Attends and actively participates in weekly staff meetings.

·           Maintains confidentiality in all aspects of operations.

·           Assist the Outpatient Manager and/or Health Services Vice President in tasks as assigned.Required Skills



·        Communicates information accurately, timely to internal and external staff.  Written and oral communication is accurate and timely and at the appropriate level.

·        Ability to articulate clinical and non-clinical information to personnel of all levels of understanding.

·        Ability to communicate with team members continuously and in a positive manner.

·        Assist education of internal and external staff in operations, policies and procedures, and regulator standards.

·        Ability to handle multiple tasks, set priorities and develop action items. 

·        Detail oriented, excellent organizational skills, highly self-motivated and dependable.

·        Team and goal oriented.Required Experience



·        Communicates information accurately, timely to internal and external staff.  Written and oral communication is accurate and timely and at the appropriate level.

·        Ability to articulate clinical and non-clinical information to personnel of all levels of understanding.

·        Ability to communicate with team members continuously and in a positive manner.

·        Assist education of internal and external staff in operations, policies and procedures, and regulator standards.

·        Ability to handle multiple tasks, set priorities and develop action items. 

·        Detail oriented, excellent organizational skills, highly self-motivated and dependable.

·        Team and goal oriented.