Pre-Certification/Utilization Review Nurse
Looking for dynamic individual that has a strong clinical background in the acute care setting, previous utilization management experience a plus, knowledgeable regarding application of Medical Necessity Criteria such as Miliman and Interqual.
This position supports Chartered’s care coordination model supports care efforts and service delivery in partnership with the member, the family defined by member (inclusive of member support network), provider, health plan staff, appropriate government entities and community based organizations. The Precertification Review Nurse is responsible for managing cases across the continuum of care to ensure easy transitions across: care delivery sites, levels of care and between practitioners. The Precertification Review Nurse promotes a member-centric approach to assuring that members receive needed care, at the appropriate time in the best place to assure an optimal outcome.
POSITION DUTIES AND RESPONSIBILITIES
- Assures that health care services are appropriately authorized.
- Coordinates transitions of care across settings, levels and practitioners.
- Facilitates referrals to other staff and to community agencies.
- Maintains a 95% accuracy rate as determined by Internal Audit Program.
- Responds to telephone inquiries from patients, hospitals, and clients by providing information within 1 business day.
- Uses clinical review guidelines to determine if a patient meets guidelines for medical necessity.
- Identifies and appropriately refers cases to supervisor and Medical Director or outside Consultant when guidelines are not met and additional review is needed.
- Reviews Consultant reports.
- Uses clinical review guidelines, Consultant reports, and other available resources to write denial language for cases that are referred to the Medical Director for a potential denial, including pharmacy denials.
- Submits denials for denial letters to be written.
- Reviews denial language on denial letters to ensure appropriateness of language.
- Acts as a resource liaison for Medical Management staff in review process.
- Adhere to established time frames for responding to requests for initial and continued service authorizations, facilitate the specification of information required for authorization decisions, provide consultation with the requesting provider when appropriate and provide for expedited responses to requests for authorization of services determined by a provider or DC Health Care Finance Administration (HCFA) to require an expedited response.
- Ensure timeframes for decisions are consistent with contractual and internal requirements and that authorization decisions are communicated to the provider of care based on contractual and internal requirements.
- Assists practitioners and hospital staff in understanding DC Plan, Inc.’s policies and procedures.
- Interfaces with claims examiners regarding utilization management issues.
- Maintains confidentiality of patient information and propriety operational information.
- Participates in Plan’s ongoing quality improvement process.
- Participate in continuing educational activities as appropriate.
- Seeks certification in utilization review and managed care nursing.
- Maintains punctual and regular attendance.
- Perform other duties as assigned.
KNOWLEDGE, SKILLS AND ABILITIES
- Bachelor of Science degree in Nursing (BSN); MSN or MS in a related field preferred.
- License/Certification - Current Registered Nurse’s license to practice nursing in DC, Maryland, or Virginia (Certified Case Manager (CCM), preferred).
- Minimum of five (5) years recent clinical nursing experience.
- Two (2) years of discharge planning, utilization review or case management experience.
- Two (2) years of managed care experience.
- Demonstrated ability to communicate with both clinical and non-clinical personnel across all levels of an organization.
- Demonstrated ability to use Microsoft Office programs; experience with databases a plus.
- Working knowledge of community resources.
- Possess working knowledge of ICD-9, HCPCS and CPT4 coding.
- May be required to travel to facilities for on-site review but this is mostly an office based job.
- Must be at corporate office for mandatory meetings and trainings, and other activities as requested by manager if job based is based off-site.
- Maintain laptop, cellular phone, and beeper provided by plan if job is based off-site.