Utilization Review Nurse

Job Description:The Utilization Review Nurse will review provider requests for services against established review criteria, referring cases not meeting criteria to a physician advisor or medical director for review. The Utilization Review Nurse will evaluate the options and services required to meet the members health and psycho-social services needs, in support and collaboration with disease management interventions. The goal of Utilization Review is to assist the provider in identifying appropriate options for the level of care that will assist the member in achieving optimum stability of health status within their defined disease state. The Utilization Review Nurse will support this effort through education, support and collaboration with the member, caregivers, treating providers, and other members of the health care team. General Responsibilities 1.Manage assigned workload within established performance standards. 2.Establish and maintain positive relationships with providers, members and caregivers through telephonic and / or onsite visits. 3.Participate in discharge planning process with hospital /or inpatient facility staff, ensuring adequate and appropriate disposition and post discharge plans. 4.Establish positive relationships with treating physicians and other health care providers through collaborative problem solving. 5.Perform Utilization Review - pre-authorization, concurrent and retrospective review as needed for inpatient/or outpatient services and/or predetermination reviews for services or levels of care requiring authorization according to the market requirements and/or policies. 6.Maintain open communication flow with internal Disease Review/Complex Case Management /or Social Services staff to facilitate smooth transition and follow-ups as member is transferred from one level of care and/or service to another. 7.Maintain all required documentation in the information systems in a timely manner. 8.Participate in case conferences, clinical in-services, and other educational opportunities. 9.Serve as a resource for recognized areas of expertise. 10.Perform other tasks as assigned by supervisor / manager. Education and Experience: 1.RN or LPN with Active, unrestricted license to practice in state of assignment. 2.3 - 5 years experience in a clinical setting required; experience in geriatric nursing, renal, cardiac and or endocrinology a plus. 3.Experience in utilization review, case management, or disease management required 4.Two years in a business / corporate setting or similar environment preferred. 5.Knowledge of Milliman Care Guide and experience in using same preferred. 6.Familiarity with utilization review modules in information systems preferred Required Knowledge, Skills and Abilities 1.Compassion and commitment to excellence in nursing, ability to communicate well with frail elderly as well as providers/vendors. 2.Ability to handle multiple tasks and variable caseload, creative problem solving and willingness to work as a team member to strategize future program enhancements. 3.Knowledge of health care delivery system, utilization review and or case Review approaches and procedures. 4.Experience of state and federal regulatory requirements affecting care coordination services, specifically CMS, Medicaid, HIPAA, etc. 5.Computer skills to include Microsoft Word, Excel and basic data entry. We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing. Company: XL Health Location: Atlanta, GA 30301 Job Status/Type: Full Time, Employee Job Category: Medical/Health Industry: Healthcare Services Occupations: Nursing Career Level: Experienced (Non-Manager)e Company: XL Health Fax: 410.625.2261 Reference Code: 10364