The UM Nurse Reviewer is accountable for clinical review and application of clinical criteria for prospective, retrospective, and concurrent authorization request in the inpatient and outpatient clinical settings.
The UM Nurse Reviewer is responsible for facilitating the authorization and clinical coordination of authorization request in compliance with the client’s defined network of providers and approval criteria.
Associates Degree preferred
Licensure / Certification
Active Unrestricted license as a Vocational (LVN) or Practical nurse (LPN)
1-year managed care experience preferred
Previous utilization management experience preferred
Core Competencies : Ethics and Values, Customer Focus, Action-Oriented, learning on the Fly, Manage / Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
Computer Proficiency (MS Word, MS Excel)
Able to utilize Interqual and / or Milliman Evidenced based criteria sets
Capacity to interpret health plan / client specific benefit guidelines and policies / procedures
Essential Functions of Job
Adheres to the client defined adjudication rules for UM Nurse Reviewer level of review
Responsible for ensuring the accuracy of member eligibility verification, member benefit verification, and network utilization to ensure accurate authorization adjudication.
Able to accurately navigate the client-based UM platform and accurately enter authorization request data
Effectively prepares authorization request for next level of review; to include, appropriate request of additional information, pre-certification verification, clinical recommendation, and accurate network utilization
Consistently meets or exceeds departmental productivity standards, quality standards, and IRR.
Compliant with turnaround timeframes for authorization adjudication and provider notification.
Ensures appropriate escalation of concerns; to include, but not limited to, Contracting issues (LOA, MOU) or Quality / Access concerns.
Appropriately identifies criteria used for clinical decision making.
Accurately and timely generation of denial or modification communication based on next level review outcomes, when applicable
Able to serve as a resource for UM Coordinators and Medical Director, when applicable
Able to perform focused provider reviews based on identified over or under utilization of services when directed.
Able to provide data in an actionable manner upon completion of focused provider reviews.
Responsible for clinical reviews for the Emergency Department to ensure appropriate clinical criteria supports an inpatient admission, when applicable.
Responsible for coordinating with hospitalists and medical directors based on client business rules to ensure appropriate admission criteria, continued stay criteria, and level of care.
Ensures timely discharge planning to safe and appropriate level of care
Responsible for exchange of information and enrollment in the transition of care program, when applicable
Responsible for adherence to the policies and procedures for the Nurse Exchange Line; to include, but not limited to, answering and managing inbound call queue from members, providers, vendors, or facilities;
accurate documentation of telephonic interventions; appropriate referral to primary provider, community resources, and / or case management;
timely follow-up calls for case closure, when applicable
Adheres to Desktop Procedures and UM Policies and Procedures
All other duties as assigned