Utilization Review Nurse I

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for leveraging clinical knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the medical necessity, level of care, and duration of treatment required for basic reviews, and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating referrals to appropriate services based on medical necessity.

Essential Responsibilities:

• Pursues effective relationships with others by sharing information with coworkers and members. Listens to and addresses performance feedback. Pursues self-development; acknowledges strengths and weaknesses, and takes action. Adapts to and learns from change, challenges, and feedback. Responds to the needs of others to support a business outcome.
• Completes routine work assignments by following procedures and policies and using data, and resources with oversight and management. Collaborates with others to address business problems; escalates issues or risks as appropriate; communicates progress and information. Adheres to established priorities, deadlines, and expectations. Identifies and speaks up for improvement opportunities.
• Supports high-quality consultation by: communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, under direct supervision; and leveraging working knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
• Supports education and compliance initiatives by: remaining up-to-date and discussing with the team the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and participating in education and training programs for staff and physicians at the local level to promote best practices in utilization management.
• Assists in quality improvement efforts by: observing and escalating utilization patterns, trends, and opportunities for improvement; learning about utilization review workflows/processes including corrective action plans and standard work, and identifying deficiencies in workflows; and learning and actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care.
• Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services, under direct supervision; and beginning to assess the ongoing need for services, identifying potential issues/delays, and recommending appropriate actions for standard member cases.