Utilization Management Nurse Reviewer
Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice. Assist in the control of utilization of resources, pre-occurrence monitoring, concurrent monitoring, intervention and retrospective review. Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives.
Duties & Responsibilities:
1. Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice.
2. Facilitate quality health care intervention recommendations.
3. Review and assess over/under utilization issues.
4. Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives.
5. Respond to inquiries by provider/site employees relating to standards of care and best practices.
6. Develop and maintain pre-established review parameters under the direction of the CMS Medical Director.
7. Identify and document comparisons with community standards, regionally based as indicated.
8. Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting.
9. Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time.
10. Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management.
11. Assist with the data collection and reporting related to the UM outpatient/inpatient process.
12. Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license.
13. Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements.
14. Assist in completion of special projects on an as needed basis.
Job Requirements:
Education: Bachelor’s degree in Nursing preferred
Bachelor’s degree in Nursing preferred
Experience Level: 3 - 5 years experience in utilization management, case management, quality management. Experience with InterQual and/or Milliman Care guidelines preferred.
Strong organizational and time management skills.
Tools and Technology: Computer usage for word processing, spreadsheets, email, internet, medical records and other proprietary company/client systems.
Certificates and Licenses: Registered Nurse (RN) active license
Language Ability: Strong verbal, written communication skills. Effectively present information in one-on-one and group situations to nursing staff, clients and other employees of the organization.
Reasoning Ability: Ability to work on extremely complex problems where analysis of situations or data requires an evaluation of intangible variance factors.
Work Environment: Office environment with occasional travel up to 10% to regional offices, client and/or vendor sites.