Utilization Review (UM) Nurse
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POST DATE 8/25/2016
END DATE 12/19/2016
Next Level Business sevices
JOB DESCRIPTIONPOSITION TITLE: Utilization Review (UM) Nurse
REPORTS TO: Operations Manager
The UM Review nurse assesses the medical necessity and quality of healthcare services by conducting the following types of requests: pre service, concurrent, and retrospective utilization management reviews.
ROLES AND RESPONSIBILITIES
* Assesses the medical necessity, quality of care, level of care and appropriateness of health care services for plan members.
* Conducts outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data.
* Applies clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided.
* Certifies cases that meet benefit/eligibility and clinical review criteria, guidelines.
* Able to manage multiple competing priorities.
* Consistently manages all work within the regulatory and contractual timeframes.
* Consults with physician when reviews do not meet clinical review criteria,
guidelines, and screens.* Refers cases to other professionals internally, including case management and medical consultation when indicated.
* Ensures the integrity and high quality of utilization management services.
* Adheres to accreditation, contractual and regulatory timeframes in performing all utilization management review processes.
* Strictly follows company policies related to the handling, release and disposal of confidential information.
* Ensures that the Operations Manager or designee is made aware of any potential risk management issues in a timely manner.
* Consistently meets medical management standards for attendance and punctuality.
* At all times treats others with dignity and respect.
* May require occasional overnight travel, particularly for training.
JOB QUALIFICATIONS AND REQUIREMENTS
EDUCATION AND LICENSURE:
* Education leading to the completion of an approved RN program
* Current, active and unrestricted US RN license. Florida RN license preferred but will consider other states.
At least 1years' experience in utilization management with a health plan, worker's comp or hospital based UM department
Experience with MCG or Interqual criteria set
* Self-motivated and able to work under pressure.
* Ability to effectively manage multiple shifting priorities.
* Able to meet deadlines and performance metrics
* Thrives in a team environment.
* Must be able to work congenially with a wide variety of individuals.
* Must be able to maintain the highest level of confidentiality and professionalism at all times.
* Must have strong oral and written communications skills.
* Must be proficient in navigating through multiple computer applications.