• Utilization Nurse - MLTC

    Job Locations US-NY-Staten Island
    ID 2018-1067
    Category
    Clinical- MLTC
    Type
    Regular Full-Time
  • Overview

    The Utilization Nurse will be responsible for reviewing authorization requests/claims for medical necessity, under the direction and supervision of the Director of UM/Transitional Service Dept.

    Responsibilities

    • Act as a liaison between the care manager and the provider
    • Reports to Director of UM/Transitional Service Dept
    • Utilizes the Utilization/Transitional Nurse Manager as a resource for all clinical questions and advice, in collaboration with Director of UM/Transitional Service Dept
    • Serve as part of the team for treatment plans. Follows up with all necessary parties regarding treatment requests
    •  Reviews the appropriateness and medical necessity of the treatment requests for utilization review on a prospective, concurrent, and retrospective basis.  Report their findings to Director of UM/Transitional Service Dept for determination
    • Reviews and assists with coordination of the POC
    • Reviews the quality and clinical risk issues on a concurrent basis; report any recognized issue to the Director of UM/Transitional Service Dept
    • Reviews the documentation in the  medical records for completeness and relationship to the treatment plan and reports findings to Director of UM/Transitional Service Dept
    • Able to obtain and interpret information appropriate to the members needs as required for assessment, treatment, and patient care services, as delegated by the Director of UM/Transitional Service Dept
    • Provide assistance and guidance to all parties with regard to  the authorization request/claim process
    • Assist with analysis of outcome data to identify and make recommendations; report issues to the Director of UM/Transitional Service Dept
    • Develop and maintain a positive work atmosphere and support the overall team; demonstrate ability to work within a team structure
    •  Practice capable and effective problem identification and resolution skills as a method of sound decision making
    • Maintain confidentiality
    • Work independently, efficiently, and deals with priorities, under the direction and supervision of the Director of UM/Transitional Service Dept.
    • Ability to function as a Utilization Nurse and any other duties as assigned
    • Practice nursing within the Scope of Practice as designated
    • Employee may be asked to travel from time to time to attend employer meetings or other offsite functions.
    • Demonstrates sound judgment by taking appropriate actions regarding suspected violation of corporate compliance regulations.
    • Reports all suspected violations to supervisor, Compliance Officer or Compliance Hotline.

    Qualifications

    • Licensed Professional Registered Nurse
    • A minimum of five (5) years of full-time employment in home health care, utilization, and nursing.
    • Excellent  verbal/written communication skills, strong organizational skills, and good judgment

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