Utilization Review Nurse

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

Hours/Schedule - M-F 8:30AM-5:00PM NICE TO HAVE skill sets/qualities: Prior hospital experience. Flexibility, comfortable learning new/multiple computer systems easily and quickly as there are multiple programs we utilize—this is a must. Prior UM and/or case management experience is preferred but not required. A typical day would like in this role: Inpatient admission review for hospitals, SNFs, rehab and LTAC facilities and continued stay reviews for all of these. Clinicals received are reviewed using Milliman & company policies. If they do not meet criteria, then a writeup is done and submitted to one of our MDs for review and a decision. Letter writing using company templates. Communicate/coordinate with case management, transplant coordinators, Team Leads, medical directors and supervisors. Expectation is to be at desk working all day except for breaks/meals. If there are children/elderly/special needs residents in the home, per policy there must be someone else available to care for them as if the employee were working in the office on site. Attend quarterly and monthly meetings via Teams. Understanding the need to be in constant communication with leadership and peers via email and Teams as priorities may shift throughout the workday and there are often new policies/issues that need to be acknowledged immediately We work closely together and are good about covering for each other when someone is out/assisting someone with an exceptionally heavy caseload or a difficult case. There is a specific Teams chat for our group to discuss things/ask questions.

Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.