Utilization Review Nurse

Company: PSW
Location: Olympia
Posted on: July 26, 2022

Job Description:

Summary / Objective: The Utilization Review Nurse performs reviews for enrollees across the service continuum (pre-certification / authorization, concurrent and retrospective reviews) utilizing InterQual, NCD, and LCD criteria to ensure the quality, quantity, timeliness and effectiveness of service. The nurse acts in a non caregiver capacity by facilitating coordination and communication between all members of the health care team in the decision making process to minimize fragmentation of the health care delivery system. As a member of the Utilization Management Department, this position is responsible for contributing to the standards of quality and service expected by both external and internal stakeholders, including ensuring accurate information flows to interdepartmental teams, proper documentation and adherence to standards related to case management activities.Essential Functions

• Reviews requests as required, performs preadmission, and concurrent reviews for appropriateness of admission, continued stay, length of stay, utilization of resources, patient outcomes and discharge planning needs.
• Includes acute patient hospital, post-acute Skilled Nursing, Long-Term Care, and Inpatient Rehab reviews for appropriateness of level of care requested.
• Use established criteria and policy/procedures to perform pre-admission, admission, and continued stay reviews on inpatient and skilled nursing cases in accordance with NCQA and CMS guidelines.
• Issue pre-authorization decisions for services requested such as Durable Medical Equipment (DME), planned surgeries, medication requests, etc.; notifying providers/enrollees of denials verbally and in writing.
• Assess need to involve medical director on complex medical costs or denials.
• Identify at-risk members in need of case/disease management programs and complete appropriate referrals.
• Works with Interdisciplinary Team (IDT) to assist with delivery of well-coordinated high quality health care, and tracking and escalation of high dollar cases.
• Assist Case Management Team with care coordination during acute episodes and transitions in care.
• Participate in department initiatives and projects focused on quality improvement.
• Participate in cross-training of clinical and non-clinical roles, as appropriate, to ensure understanding of processes driving compliance, turnaround times, and authorization workload tracking.
• Document all interventions and telephone encounters with providers, members and vendors in accordance with established documentation standards.
• Exceed expectations in professional and personalized service level to internal and external partners.
• Implement new policies, procedures and initiatives as assigned and ensure all areas are maintained in accordance with company policy, state, federal and plan regulatory mandates.
• Support technology implementations focused on opportunities to scale and automate components of the UM process to improve compliance tracking (e.g. fax software, authorization system upgrades, etc.)
• Collaborates with internal and external healthcare team members to achieve organizational IP, ED, SNF utilization, length-of-stay, and readmission goals.
• Build and leverage cross-functional collaborative relationships to support tracking of inter-related utilization, cost, and claims reconciliation initiatives.
• Promotes continuity of care and cost effectiveness through integrating functions of case management and utilization review to identify barriers to optimal patient care.
• Assess member physical, psychological and discharge planning needs through communication with appropriate care providers to coordinate care accordingly.
• Work with members and providers to enhance the quality of patient management and satisfaction.
• Prepares and provides reports to leadership, other departments, and outside agencies as needed.
• Support comprehensive training for new employees to ensure mastery of work product and clear expectations.
• Continues own education by keeping knowledge current and familiarity with guidelines to strengthen general understanding of state and federal resources to support position responsibilities.
• Ensures compliance with departmental and PSW policies and procedures, with special emphasis on compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.
• Is aware of and continually supports strategic plans that ensure company objectives and goals are obtained.Required Education and/or Work Experience:
  • Minimum 2 years of experience in UM/UR.
  • Verifiable experience or knowledge of a variety of clinical areas of medical treatment.
  • Knowledge of hospital/patient care facilities, current practices, procedures, acceptable medical treatment and diagnoses.
  • PSW requires all employees and contractors to be fully vaccinated for COVID-19 as a condition of employment, subject to reasonable accommodation. Each TRC health system requires visitors adhere to its own COVID policy.Preferred Education and/or Work Experience:
    • Case Manager Certification.
    • Experience with health plan/HMO utilization review/management and/or case management experience.
    • Knowledge of Interqual and/or Milliman Utilization Criteria.
    • Experience working with Medicare Advantage/CMS.

Keywords: PSW, Olympia , Utilization Review Nurse, Healthcare , Olympia, Washington