Health Nurse - Utilization Review

Position Title Health Nurse – Utilization Review Nurse Reports To VP, Clinical Program Strategy and Integration Department Health and Quality Management Position Summary A Utilization Review Nurse (aka Health Nurse) at Alterwood Health is compassionate and resourceful in bringing positive change to members’ health. Health Nurses are responsible for reviewing provider requests, including medical records for outpatient medical procedures/services and durable medical equipment (DME), and to determine the medical necessity for such services. Health Nurse will collaborate with their counterparts in Case Management to ensure the safe transition of members from the inpatient to the outpatient setting.

Research and apply national care guidelines such as Medicare National or Local Coverage Determinations, MCG, or InterQual to concurrent and preservice prior authorization (PA) requests. Process PA requests in a timeline fashion according to Medicare requirements. Collaborate with medical director and other specialists in the final disposition of certain PA requests. Provides support and facilitates arrangements for transitional of care activities and promotes continuity of care for members’ safe admissions, transfers, and discharges from hospital to skilled nursing and/or to home. Maintains collaborative working relationships with members’ providers, the appropriate state agencies, delegated vendors, and community providers/facilities. May perform duties telephonically as well as conducting on-site visits, if needed. Prepares, completes, and maintains clinical documentation in clinical systems through written case records/notes and performs case follow-up and closer, and performs other administrative tasks as required and in accordance with best practices and Medicare/Federal guidelines. Perform any other job-related instructions, as requested.