Utilization Review Nurse RN

Victorville, CA

• Coordinates and reviews all medical records, as assigned to caseload
• Actively participates in Case Management and Treatment Team meetings
• Serves as on-going educator to all departments
• Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
• Able to work independently and use sound judgment.
• Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
• Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
• Responsible for providing timely and accurate referral determination
• Identification of referrals to the medical director for review
• Appropriate letter language and coding (denials, deferrals, modifications)
• Appropriate selection of the preferred and contracted providers
• Proper identification of eligibility and health plan benefits
• Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• Performs other duties as assigned.
  

EDUCATION & EXPERIENCE REQUIREMENTS:

• CA LVN license required. CA RN license preferred.
• Bachelor’s or Master’s degree in Social Work, behavioral or mental health, nursing or other related health field preferred
• 3 to 5 years of acute care experience preferred.
• Two (2) years managed care experience in UM/CM Department, preferred
  

SKILLS & ABILITIES REQUIREMENTS:

• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
• ICD-9 and CPT coding experience a plus
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
• Experience in EZ-CAP preferred
• Medical Terminology preferred