Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning Evaluates and provides feedback to member’s providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriateĪs part of the hospital prior authorization process, responsible for determining “observational” vs. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Performs concurrent and retrospective reviews on all facility (hospital, skilled nursing facility, and acute rehabilitation) and appropriate home health services. Knowledge of or experience with Milliman Care GuidelinesĮxperience in discharge planning or chart review Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environmentĪbility to obtain favorable adjudication following submission of Department of Defense eQuip Form SF86 Works with less structured, more complex issuesģ years of clinical experience in an inpatient/acute setting Works with minimal guidance seeks guidance on only the most complex tasks Referring patients to disease management or case management programsĪssisting with the development of treatment plans Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment planĮscalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate Performing care management activities to ensure that patients move through the continuum of care efficiently and safely InterQual or Milliman Knowledge/experience Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills Proficient in PC software computer skillsĮxcellent communication skills both verbal and written skillsĪbility to interact productively with individuals and with multidisciplinary teams Strong problem solving and analytical skills Identify and refer potential cases to Disease Management and Case ManagementĬurrent RN license, applicable for practice in the applicable stateĢ years of experience in managed care OR 5 years of nursing experience Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance DepartmentĬonducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologiesĭocuments rate negotiation accurately for proper claims adjudication May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses Sends appropriate system-generated letters to provider and member Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care servicesĪnswers Utilization Management directed telephone calls managing them in a professional and competent manner Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelinesĭetermines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria
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