The RN, Utilization Management Referral nurse will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines. The RN, UM Referral nurse will support the UM leadership team to provide guidance for processing of referrals. The RN, UM Referral Nurse may review retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. The RN, UM Referral Nurse may be involved in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting. The RN, UM Referral Nurse may provide oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable. The RN, UM Referral nurse serves as the lead UM Referral nurse and supports the leadership team in maintaining compliance with regulatory guidelines.
Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan
Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective
Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria.
Assists with composing medical director denials to meet language requirements set by ICE/Health Plan requirements
Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making
Maintains up to date knowledge of rules and regulations governing utilization management processes;
Input data into the Medical Management system to ensure timeliness of referral processing.
Verifies member benefits and eligibility upon receipt of the treatment authorization request.
Ensure timely provider and member oral and written notification of referral decisions.
Coordinates with Medical Director or referral specialists for timely referral processing
Facilitates LOA processing by sending request to Provider Contracting for non-contracted providers or facilities, when applicable
Facilitates LOA processing with the Health Plan for non-contracted facilities
Performs trouble-shooting when problems situations arise; taking independent action to resolve the less complex issues.
Assist supervisor/manager in quality assurance processes and education of staff
May be responsible for daily concurrent review, retro reviews, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based criteria.
Will participate in the developing of all program material, Policies and Procedures related to the medical management; to include, the development of informational and educational materials
Develops a positive working relationship with internal and external customers
Perform additional duties as assigned.
EXCEEDS PERFORMANCE REQUIREMENTS
Meets the established Performance & Productivity Targets for area (s) of accountability. Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks.
Met target on 90% of the Department’s Performance Metrics as it relates to core job function.
Exceeds targeted productivity standard
Identifies a core area for performance improvement and independently creates training material
Minimum of 2 years of managed care experience
Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.
Exceptional oral and written skills.
Excellent customer service; ability to be an effective communicator
Excellent critical thinking, deductive reasoning and decision making skills.
Ability to work as a team member and participate in the assessment and evaluation process of potential and existing participants.
Fosters a cooperative and harmonious working climate conducive to maximize employee morale and productivity.
Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.
Ability to work collaboratively with diverse individuals and situations, including strong problem solving and conflict resolution skills.