Medical Management Nurse 1

Reporting to the Medical Management Director. The title of this role is Medical Management Nurse. The role required a current and unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license, with TX licensure required within six (6) months of employment. This is a part time role requiring coverage for each Saturday, Sunday and holidays. Hours of operation are 9AM CST to 3PM CST. Additional coverage to meet department needs may be scheduled as mutually agreed upon. The nurse shall facilitate the timely processing of authorization requests, after verification of eligibility and make certain that clinical information is provided to support a timely review determination. This position requires working knowledge of UM Criteria, including Medicare National Coverage Determinations (NCD) and Local Coverage Determination (LCD) criteria and guidelines, Health Plan criteria, Milliman Care Guidelines (MCG), ICD.9/10, CPT Coding and Medical Terminology.

Following established departmental processes and guidelines, the MM Nurse 1 reviewer reviews authorizations and applies specific medical necessity guidelines for approval of requests. Review on a concurrent basis, ongoing care at the acute, skilled, home care levels to determine appropriateness of continued care at the current level of care Make certain that all referrals are processed in a timely manner and support compliance with appropriate turnaround timeframes Responsible for checking the referral for completeness of supporting clinical information and obtaining missing medical records or clinical information as needed in support of a thorough review and appropriate review outcome. Responsible for meeting accuracy standards for appropriate authorizations of referrals. Utilize and apply medical necessity criteria based on the organization’s established hierarchy When unable to approve the authorization, prepares information to be sent to the UM Medical leader for further review and determination. Support compliance with applicable laws, regulations, procedures, and policies.