After Hours Utilization Management Nurse On Call
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Performs telephonic medical necessity reviews utilizing established and evidenced based criteria on all designated pre-certification requests, as well as targeted outpatient procedures, services and inpatient admissions. Essential duties include but not limited to prospective review of outpatient and inpatient admissions and/or services; concurrent review and discharge planning for all members admitted to acute, sub-acute and/or skilled nursing facilities; retrospective review for services not pre-certified and/or reconsiderations. In collaboration with physician and healthcare team, facilitate appropriate resource utilization within contracted and non-contracted facilities. Evaluates eligibility and benefit information and educates member and/or family, physician and interdisciplinary healthcare team as to meet the health needs of the member and minimize out of pocket costs. Identify and refer appropriate members to case management, disease management, risk management and quality improvement. Establish relationships and communicate with members, family, inpatient and outpatient providers and case managers, community resources, skilled nursing staff, members service, claims, contracts, benefits, appeals, risk and quality management.
- Utilizes established criteria to perform pre-certification review for all members requiring a procedure or service or with an admission diagnosis on the targeted review list.
- Obtains clinical data and determines medical necessity for pre-admission, admission, concurrent and retrospective review for contracted and non-contracted facilities utilizing established guidelines and/or criteria.
- Performs assessment of physiological, psychosocial and functional status to facilitate early discharge planning in collaboration with patient and/or family, physician and interdisciplinary healthcare team.
- Facilitates and coordinates discharge planning interventions along with quality of care, while ensuring utilization of resources is seamless along the continuum, based on the needs of the individual patients and availability of local delivery system.
- All referrals, pre-certification, concurrent and retrospective reviews will be performed and the provider and member notified of the results within the regulatory required timeframe.
- Educates physicians, other members of healthcare team, and patient and/or family regarding interpretation and application of Medicare, Medicaid and Health plan benefits and coverage and its interrelationships with efficient and appropriate resource utilization and member out of pocket costs.
- Investigates, prepares and refers cases not meeting established criteria and/or requiring Medical Director (QRM) review per established department guidelines.
- Inserts appropriate physician and/or coverage language and issues letters of non - coverage to members not meeting established medical necessity criteria and ensures patient and/or family understand appeal rights and assist with alternative resources if able and available.
- Collaborates with physicians and providers to ensure that healthcare resources are provided at the appropriate level of care and in the most appropriate setting based on established criteria or guidelines.
- Identify per program criteria and refer appropriate members to case management, disease management, risk management and quality improvement.
- Coordinates transmission of clinical and benefit information to patient, family, physician and/or provider remaining HIPPA compliant.
- Provide correspondence, written and verbal, in accordance to policy and procedure for members with respect to status of pre-certification and utilization review.
- Per established protocols or triggers, reports any incidence of unusual occurrences to quality, risk and/or patient safety to the appropriate entities.
- Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements, Nurse Practice Act and laws that affect managed care and case/utilization management.
- On-call hours will be Pacific Standard time:
- Other duties as assigned.
- Minimum three (3) years Utilization Management experience, to include discharge planning and quality improvement in a managed care setting.
- Minimum three (3) years of clinical nursing.
- Graduate of an accredited school of nursing.
- Registered Nurse License (California) OR Vocational Nurse License (California)
- Registered Nurse License (in the state where care is provided) required at hire OR Licensed Practical Nurse (in location where applicable) required at hire
- Drivers License (in location where applicable)
- Working knowledge of all local, state and federal and regulatory requirements.
- Excellent organizational, oral and written communication and problem-solving and decision making skills.
- Professional image and behavior.
- Excellent windows-based navigation skills.
- Three (3) or more years experience in a Preferred Provider Organization preferred.
- Experience with URAC and/or NCQA accreditation process preferred.
- Bachelor's degree in nursing or healthcare preferred.
- Excellent analytical skills preferred.