Purpose Statement / Position Summary
Under minimal supervision and using clinical experience, evidence based knowledge and in collaboration with our physicians, to process clinically appropriate care management referrals.
Essential Functions and Responsibilities of the Job
Utilization Review Nurse Responsibilities:
- Along with physician hospitalists / PCPs / Specialists, leads and coordinates activities of interdisciplinary treatment team required to make complex clinical, benefit and network decisions.
- Apply Utilization Review Management process to ensure continuity of care throughout the health care continuum including review and authorization of services applying evidence-based guidelines and per MemorialCare Medical Foundation policy.
- Assures review turnaround times adhere to timeliness standards set by contracting and regulatory requirements and established productivity and quality guidelines.
- Decisions and documentation demonstrates prudent utilization of resources, identifies for potential cost reduction; promote quality care and comply with regulatory guidelines needed to maintain delegated status from contracted health plans.
- Documents decisions that demonstrate independent judgment, critical thinking and application of complex managed care regulations including but not limited to benefit structures, health plan coverage, medical necessity, network contract, financial responsibility and care management.
- Implement and maintain systems and processes that meet various regulatory requirements.
- Interprets and applies delegation agreements, divisions of financial responsibility, contracted provider lists, evidence of coverage, health plan operations manuals, and MemorialCare Foundation policy.
- Independently research and determine the information necessary to satisfy specific business and regulatory medical management requirements. Initiate and complete the denial process for all services deemed to be non-covered benefits or not medically necessary.
- Maintain and demonstrate a complete understanding of own scope of practice of licensure and education level.
- Monitors utilization and provides recommendations for improvement against established industry standards and performance measurement metrics.
- Works with Managers to oversee approval, denial and appeal process, including implementation of appropriate denial letter language to meet regulatory standards.
- Participates in Contracting and Provider Relations activities as necessary to develop and maintain provider networks.
- Subject to standard medical management performance measurements for specific area/team including but not limited to referral turnaround times, volume, denial language and overturn rates.
- May be required to travel during shift for meetings and staff oversite.
- May be required to work remote to meet business needs for regulatory compliance.
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