Utlization Review Nurse-Select Health - Registered Nurse (RN)

Proactively manage inpatient and outpatient utilization to assure that medical care is appropriate, efficient, and medically necessary. Support facility discharge planning efforts, coordination of transition of care and manage utilization through appropriate review of authorization requests. <br>

Job Essentials

Analyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification standards.
Implements utilization management processes and coordinate medical services with other SelectHealth and Intermountain departments, as well as local, state and federal programs (Medicare, Medicaid, etc.)
Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization.
Proactively and collaboratively interfaces with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care. Resolves member, family/caregiver assistance requests.
Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home Health agency services. Performs retrospective reviews as needed for services rendered without an authorization.
Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care. Coordinates with specialty vendors or providers for post-acute care needs.
Contributes to the development and maintenance of policies and procedures to ensure regulatory compliance, identifying new policies and procedures that are required. Complies with all standards pertaining to accreditation (NCQA or other regulatory bodies).
Demonstrates a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to effectively identify opportunities and coordinate referrals for care management intervention.
Perform all required documentation and entry into utilization management operating system for authorization and determination.
Contribute to the effectiveness and efficiency of the department. Participate in the documentation of the utilization management program, work plan, and annual evaluation including necessary submission to accreditation or other regulatory bodies.
Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member satisfaction.
Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards.
Consistently adhere to department productivity and performance expectations.
Consistently demonstrates an attitude of customer service excellence to both internal and external customers.



Minimum Qualifications

Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.

Current RN license in state of practice.

Three years clinical nursing experience.
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One year in Managed Care, Utilization Management, or Case Management.
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Basic computer skills including word processing and spread sheets.
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Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively.

Preferred Qualifications

• Behavioral Health Experience.

Current working knowledge of Medicare, Medicaid and Commercial insurance.
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Current working knowledge of utilization management and case management techniques.
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Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
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Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.

Physical Requirements:

Ongoing need for employee to see and read information, assess member needs and view computer monitors.
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Frequent interactions with providers, members that require employee to verbally communicate as well as her and understand spoken information, needs and issues accurately.

Location:

SelectHealth - Murray

Work City:

Murray

Work State:

Utah

Scheduled Weekly Hours:

40