Full-Time UM Nurse Reviewer
Job Description
Job Description Summary
Optimize member benefits to promote effective use of resources. Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house. Discuss cases with attending physician and other health care professionals. Prepare and refer concerns to plan Medical Directors.
What you will do:
Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the appropriateness and continuity of care.
Apply all aspects of the medical review function, including pre-authorization, concurrent review, screening for quality-of-care issues, and discharge planning. Document rationale for medical decisions made.
Identify at-risk members who would benefit from health management programs through comprehensive health assessments.
Monitor and evaluate patient’s plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions.
Promote member and provider satisfaction. Provide continuity and consistency of care by building positive relationships between member and family, physicians, provider, care coordinator, and health care plan. Represent corporation in a responsible and professional manner.
Participate in department initiatives and projects.
Perform other duties as assigned.
What you’ll need to succeed:
Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC)
Three to five years acute medical or clinical experience or experience in utilization reviewed.
Valid Driver’s License (On-site only)
Understanding of utilization review techniques including all aspects of the medical review function, including pre-authorization, concurrent review and discharge planning
Understanding of health care delivery system access points and services
Correct application of health care management guidelines
Ability to navigate the healthcare delivery system
Advanced analytical skills, with the ability to interpret and synthesize complex data sets
Good business acumen and political savvy
Knowledge of business process improvement techniques and strategies
Excellent verbal and written communications skills
Negotiation skills
Presentation skills
Decision-making skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to effectively navigate ambiguous situations with limited direction
Excellent organizational skills and ability to successfully prioritize multiple tasks
Ability to handle multiple priorities/projects
The extras:
Bachelor’s Degree in Nursing
Certified Case Management certification, Certified Professional Utilization Review certification
Experience working in a managed care/health maintenance organization
How to Apply
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