Utilization Review Nurse, Ambulatory Care - FT/Days (8:00AM-5:00PM)

Location: 
MMF-Medical Foundation
Schedule: 
Full Time
Shift: 
Day Job
Job Listing: 
MEM003900
Nurses

Essential Functions and Responsibilities of the Job

  • Alongwithphysicianhospitalists/PCPs / Specialists,leadsandcoordinatesactivitiesof interdisciplinarytreatmentteamrequiredtomakecomplexclinical,benefitandnetworkdecisions.

  • Analyzedatatoidentifyunder/overutilization;improveresourceconsumption;promotepotential reductionincost;andenhancequalityofcareconsistentwithMemorialCareMedicalFoundation strategicgoalsandobjectives.

  • Apply Utilization ReviewManagementprocesstoensurecontinuityofcarethroughoutthehealthcare continuumincludingreviewandauthorizationofservicesapplyingevidence-basedguidelinesand perMemorialCareMedicalFoundationpolicy.

  • Assuresreviewturnaroundtimesadhereto timelinessstandardssetbycontractingandregulatory requirementsandestablishedproductivityandqualityguidelines.

  • Decisionsanddocumentationdemonstratesprudentutilizationofresources,identifies forpotentialcostreduction;promotequalitycareandcomplywithregulatory guidelinesneededtomaintaindelegatedstatusfromcontractedhealthplans.

  • Assists with developingcorrectiveactionplans,createpoliciesanddesignworkflowsthatoperationalize improvementsidentifiedthroughdata and leadershipanalysis.

  • Documentsdecisionsthatdemonstrateindependentjudgment,criticalthinkingandapplicationof complexmanagedcareregulationsincludingbut notlimited tobenefitstructures, health plan coverage, medicalnecessity,networkcontract,financialresponsibilityandcaremanagement.

  • Implementandmaintainsystemsandprocessesthatmeetvariousregulatoryrequirements.

  • Interpretsandappliesdelegationagreements,divisionsoffinancialresponsibility,contracted providerlists,evidenceofcoverage,healthplanoperationsmanuals,and MemorialCareFoundationpolicy.

  • Independentlyresearchanddeterminetheinformationnecessarytosatisfyspecificbusinessand regulatorymedicalmanagementrequirements. Initiateandcompletethedenialprocessforall servicesdeemedtobe non-coveredbenefitsornot medicallynecessary.

  • May be called upon to participateinregulatorycomplianceauditrequirementsandactivities/committeesincludingbutnotlimited toUtilizationManagement,QualityImprovementand PerformanceImprovement.

  • Maintainanddemonstrateacompleteunderstandingofownscopeofpracticeoflicensure and educationlevel.

  • Monitorsutilizationandprovidesrecommendationsforimprovementagainstestablishedindustry standardsandperformancemeasurementmetrics.

  • Works with Managers to overseeapproval,denial andappealprocess,includingimplementationofappropriatedenialletter languagetomeetregulatorystandards.

  • ParticipatesinContractingandProviderRelationsactivitiesasnecessarytodevelopandmaintainprovidernetworks.

  • Subjecttostandardmedicalmanagementperformancemeasurementsforspecificarea/team includingbut notlimitedtoreferralturnaroundtimes,volume,deniallanguageandoverturnrates.

  • May be required to travel during shift for meetings and staff oversite.

  • May be required to work remote to meet business needs for regulatory compliance.

Qualifications: 

Qualifications/Education Requirements

Required:

  • Minimum2 yearsofutilization/ caremanagementexperienceapplyingevidence-based criteria (i.e.:Milliman,Interqual);Healthplanmedicalpolicy/clinicalcoverageguidelines.

Preferred:

  • Experienceperformingmedicalmanagement(UM)inelectronicreferral application preferred.
  • NavigationofSharePointorequivalentexperiencenavigatinginternalcompanyintranet preferred.
  • 2 years�workexperienceinMicrosoftWord,MicrosoftExcelandMicrosoftOutlook
  • CaliforniaRegisteredNurse(RN) preferred or LVN with related UM experience.
  • BachelorofScienceNursingorrelatedfieldofstudypreferred.
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