Structurecare Reviews Jobs in Usa

Summary:

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
• Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
• Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. 
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:

Education/Skills

• Graduate of an accredited school of vocational nursing or equivalent required
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred

Experience

• 3 – 5 years of nursing experience preferred
• Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
• General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

• LVN license in the state of employment or compact required
• RN license in state of employment or compact preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

The challenges of affordable healthcare continue to create new opportunities.

Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs.

These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Care Management Supervisor of Quality Review & Staff Education is responsible for quality assurance, accuracy, and overall integrity of the care management records completed by Care Management staff. This role is to ensure compliance with NYS DOH and CMS regulations through development of auditing tools and data validation. This Supervisor will analyze collected audit data, identify trends for staff re-training, and implement corrective action plans in collaboration with Clinical Management and Staff Education. They will oversee and conduct orientation, training, and education to all members of the Care Management team. Provides support to Director and Managers of Coordinated Care to ensure that all reporting requirements are prepared, submitted, and maintained in a professional and well-coordinated manner.

• Baccalaureate Nursing Degree from an NLN-Accredited School of Nursing
• Experience and knowledge of Managed Care: A minimum of two years nursing experience in Community Health or related field and/or minimum of two years of progressive job-related experience, including care management and coordination, education and supervision
• Demonstrates strong critical-thinking, problem-solving skills, and knowledge of Medicare and Medicaid
• Effective communication skills both written and oral
• Possesses strong critical thinking skills and knowledge of Medicare and Medicaid regulations
• Excellent analytical skills, interpretation of data
• Ability to set priorities and to handle multiple assignments
• Working knowledge of audit techniques and methodologies
• Secures relevant information to identify potential problems and makes recommendations for appropriate solutions
• Work effectively within interdisciplinary team environment
• Computer literate, Windows, Excel, Word, Visio and data base programs required. PowerPoint preferred
• Working knowledge of State and Federal regulations

Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.

Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.

Provides support for claim appeals in relation to medical necessity.

Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.

Facilitates member second level appeal process.

Graduate from an accredited school of professional nursing is required.

BSN preferred.

Minimum 2 years acute care experience or managed care experience is required.

Basic knowledge of Medicaid, Medicare preferred.

Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.

Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.

Active Certification in Case Management (CCM) is preferred.

Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.

Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.

Provides support for claim appeals in relation to medical necessity.

Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.

Facilitates member second level appeal process.

Graduate from an accredited school of professional nursing is required.

BSN preferred.

Minimum 2 years acute care experience or managed care experience is required.

Basic knowledge of Medicaid, Medicare preferred.

Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.

Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.

Active Certification in Case Management (CCM) is preferred.

The Utilization Review Physician collaborates with the healthcare team in the management and resolution of activities that assure the integrity of clinical records for the patient population and Hackensack University Medical Center.

These include but are not limited to utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care, as outlined in the responsibilities below.

Education, Knowledge, Skills and Abilities Required: 1.