About the position The Utilization Review Nurse ensures that authorization requests, provider and member clinical inquiries are processed timely and handled appropriately within member’s plan benefits coverage and established clinical guidelines utilized for appropriate clinical decision-making. Functions collaboratively with individuals within the Utilization Management team, and specifically with the inpatient review nurses, Case Managers, and Medical Directors to ensure timely determination of inpatient and outpatient medical services authorization requests.

Responsibilities

• Perform review of requests for services/procedures including, but not limited to, elective surgery (inpatient and outpatient), skilled nursing facility and therapy services, durable medical equipment (DME) and supplies that require medical necessity review and/or benefit interpretation.
• Use of established medical criteria to approve services based on information obtained from attending physician and/or other providers/
• Ensure full collection of clinical information prior to rendering a decision.
• Ensure timely determination of requests according to established processing time-frames.
• Contact providers where additional information is necessary to make a decision.
• Consult with Medical Director a appropriate for all requests that do not meet criteria and inform providers of the Medical Director's decisions.
• Act as a member/family advocate in coordinating and accessing medical necessity health care services within the benefit plan.
• Respond to member/member's authorized representative questions regarding the disposition of a request and/or the decision.
• Manage workload needs on a concurrent basis, including authorization queues and fax queues in the UM department ot concurrently prioritize self-assignment for greater impact on department function.
• Support on-boarding program for UM staff by acting as primary mentor for review nurses.
• In conjunction with medical leadership, act as resource for criteria and benefit interpretation including the correct and consistent application of the clinical practice guidelines/criteria on the appropriate topics, consistent application of procedural practices established.
• Complete authorization process in UM data management system for approved authorizations and contact providers with decision and corporate authorization number.
• Achieve performance and productivity metrics
• Create and fax/mail determination letters to members/providers as required and within established time-frames and wit desired accuracy.
• Receive and process clinical updates for continuation of services.
• Participate in process improvement initiatives that improve the customer experience, enhance work-flow, and/or improve the work environment.
• Other special projects and duties, as assigned.

Requirements

• Current license (without restriction) to practice as a Registered Nurse (RN) with a multistate license.
• Effective verbal and written English communication skills.
• Demonstrated intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.
• Highest level of professionalism with the ability to maintain confidentiality.
• Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.
• Customer service oriented with the ability to work well under pressure.
• Strong attention to detail and accuracy, excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Strong analytical and problem-solving skills.
• Ability to take initiative and make suggestions for improvements.
• Ability to work with minimal supervision, take initiative and make independent decisions.
• Ability to deal with new tasks without the benefit of written procedures.
• Approachable flexible and adaptable to change.
• Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and vendors.
• LICENSE/CERTIFICATION/OTHER SPECIAL REQUIREMENTS Current license (without restriction) to practice as a Registered Nurse (RN) with a multistate license

Nice-to-haves

• At least one year experience in UM/UR and managed care experience is preferred.
• Knowledge of medical/surgical terminology and Medicare managed care authorization processes.