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Utilization Review Nurse

The Nurse reviewer performs written or telephonic assessments and utilization reviews, across the continuum of care for inpatients and outpatients. The Nurse Reviewer identifies plans, coordinates, and implements high-quality, cost-effective alternatives when appropriate to the patient’s condition. The Nurse Reviewer supports physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes. The Nurse Reviewer reviews inpatient and outpatient authorization requests and performs Claims audit reviews for claims billed without prior authorization approval. The Nurse Reviewer understands and effectively communicates requirements and follows CCHP policies and procedures. The Nurse Reviewer accurately tracks as well as reports utilization and quality data.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Performs concurrent review to assure appropriateness of admission, continued inpatient/acute rehabilitation/SNF status, and discharge using established InterQual guidelines or industry standards. Optimize the quality of care and utilize cost-effective standards of practice.

2. Assures appropriate utilization of outpatient resources that maximize the adherence to evidence-based guidelines and high standards of quality care.

3. Identifies, coordinates and implements high-quality care and appropriate ancillary care by focusing on the continuum of care and patient’s medical needs.

4. Collaborates with facility case managers and physicians to assure their participation and compliance with post-discharge arrangements.

5. Collaborates with clinical social services in complex cases seeking assistance to improve the long-term care plans for the patient.

6. Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.

7. Evaluates all post-acute care services and documents information into the Case Coordination management system.

8. Initiates decertification or downgrades review process of inappropriate admissions and inpatient days based on evidence-based clinical criteria (i.e. InterQual) in collaboration with UM Manager and Medical Director. Delivers written notification to patient or family members and communicates with members of the health care team as required.

9. Regularly communicates with the UM Manager, Medical Director, physician advisor/reviewer, and primary care physician for support, problem resolution, and for notification of decertification and appeals.

10. Authorizes requests for services using State and Federal Mandates/Guidelines, Member Benefits, CCHP Medical Policies (or other Health Plans Medical Policies for third-party administration plans), InterQual clinical guidelines; refers questionable cases to the UM Manager or Medical Director for determination.

11. Collects and reports utilization data and quality information, such as delays in service, possible avoidable days, readmissions, length of stays, etc.

12. Participates as part of the care management team works collaboratively with all department staff. Catastrophic case management as assigned.

13. Participates in UM audits as requested.

14. Accepts and performs other duties as assigned.

QUALIFICATIONS

Current unrestricted California RN license
Bachelor’s degree or equivalent
Master’s degree preferred
Complex Case Management preferred
Minimum two years acute inpatient care experienced required
At least one-year recent utilization management, discharge planning, or case management experience preferred

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 10/26/2021 4:42:11 PM