The US Registered Nurse Analyst is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources.
Duties and Responsibilities :
Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.
Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and / or Client's medical staff for review
Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above, but excludes denial determinations.
Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and / or prior authorization.
Verify benefits and / or eligibility information. Check benefits for facility-based treatment.
Review of information and summarization of member's potential care needs and / or durable medical equipment (DME) needs following discharge and forward to client for final discharge plan.
Conduct PSCCR claims review utilizing the member's benefit contract and health plan guidelines.
Consult with clinical reviewers and / or U.S. - licensed medical directors to approve medically appropriate, high quality, cost effective care throughout the PSCCR process.
Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Determine contract and benefit eligibility; obtain intake (demographic) information from callers and / or faxes.
Conduct a thorough radius search in "Provider Finder" and follow up with provider on referrals given; refers cases requiring clinical review to a nurse reviewer.
Responsible for reporting known or suspected data breaches on the day of discovery to a Team Lead or Manager.
Graduate of Bachelor of Science in Nursing (BSN)
Must have at least 3 months’ work experience as a Registered Nurse in a clinical setting
Must have an active USRN License
Holds current and unrestricted US Registered Nurse license (state-specific RN licensure)