Utilization Review Nurse

Job Title: Utilization Review Nurse

Position Type: Part-Time (Every other weekend - Saturday and Sunday, totaling 30 hours per month)

Training Requirement: Candidates must be available M-F during typical business hours for a 4-week training period.

Job Summary: The Care Management Coordinator is responsible for evaluating members' clinical conditions through the review of medical records to determine the medical necessity of services. This role involves direct interaction with providers to obtain additional clinical information when necessary. The Care Management Coordinator has the authority to authorize medically necessary services based on their review but must refer cases that do not meet established criteria to the Medical Director. This role ensures regulatory compliance and acts as a patient advocate and resource for navigating the healthcare system.

Key Responsibilities:

• Apply critical thinking and judgment skills based on advanced medical knowledge to determine medical appropriateness using specified resources and guidelines.
• Use InterQual criteria and Medical Policy to establish the need for inpatient stays, procedures, and ancillary services.
• Contact providers to discuss treatment plans and clarify medical needs.
• Review and clarify treatment plans for requested services, inpatient admissions, or continued stays.
• Refer cases not meeting established criteria to the Medical Director for further evaluation.
• Identify members needing discharge planning early and collaborate with case management staff or physicians to facilitate discharge to the appropriate setting.
• Report potential utilization issues or trends and provide recommendations for improvement.
• Refer cases to the Quality Management Department and/or Care Management and Coordination Manager as needed.
• Ensure requests are covered within the members' benefit plans and comply with state, federal, and accreditation regulations.
• Meet regulatory turnaround times and departmental productivity goals.
• Maintain accurate and timely data entry in the system.

Qualifications:

Education:

• Active PA Licensed RN
• BSN preferred

Experience:

• Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.
• Prior discharge planning and/or utilization management experience is desirable.
• Medical management/precertification experience preferred.

Knowledge & Skills:

• Exceptional communication, problem-solving, and interpersonal skills.
• Strong ability to set priorities and achieve results.
• Team player with the ability to build team spirit and interdepartmental rapport.
• Open to change and comfortable with new ideas and methods.
• Respectful of workforce diversity and colleagues.
• Excellent organizational and prioritizing skills.
• Effective time management.
• Knowledgeable about current medical practice trends.
• Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs, with the ability to learn new systems.