Per Diem Clinical Care Reviewer, RN
Under the supervision of the Supervisor, Utilization Management, the Clinical Care Review Nurse is responsible for completing medical necessity reviews using policies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge planning requests Consistently applies medical health benefit policy and medical management guidelines to authorize services. Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met.
- Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
- Verifies and documents member eligibility for services.
- Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
- Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
- Applies submitted information to authorization process (utilizing Milliman, USA, Interqual medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
- Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information.
- Refers cases to Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
- Documents case activities for Utilization determinations and discharge planning in medical management platform in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.
- Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner.
- Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
- Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
- Recognizes opportunities for referrals to Care Coordination Department, and refers accordingly.
- Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
- Maintains awareness and complies with authorization timeliness standards based on DPW/NCQ requirements.
- Current and unrestricted Registered Nurse license.
- Graduate from an accredited Diploma, Associate's Degree or Bachelor’s Degree nursing program.
- Minimum of 3 years of direct patient care experience as a Registered Nurse in a related clinical setting.
- Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization.
- Working knowledge of criteria (InterQual preferred) to help determine the appropriateness of care.
- Ability to attend virtual/online training Monday through Friday between 8a and 5p, for minimum of 2 weeks, depending on assignment.
- Ability to work up to 15 hours per week based on business needs.
- Ability to provide a minimum of 30 hours of availability per month.
- Ability to work flexible hours during standard business hours (e.g. 8a to 5p), 6 hours per shift minimum, which may include evenings or weekends, depending on business needs.