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.
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
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.
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