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Role Description

In this role, you will play a vital part in ensuring our members receive the right care at the right time. You will conduct clinical reviews of inpatient and outpatient services to assess medical necessity and appropriate length of stay, aligning decisions with departmental standards and Medicare guidelines.

Beyond clinical review, you will collaborate closely with inpatient case managers, physicians, and community resources to support seamless care transitions. Through proactive discharge planning and care coordination, you will help guide members safely between care settings while promoting high-quality, cost-effective outcomes.

Qualifications

• Licensed Registered Nurse (RN) in the state of residence is required, with the ability to obtain additional state licensure as needed
• 3+ years clinical nursing experience or the knowledge, skills, and abilities to succeed in the role
• Strong verbal and written communication skills
• Strong ability to use good judgment
• Strong effective organizational and customer service skills
• Working knowledge of contract terms as it relates to utilization management program compliance and reimbursement
• Working knowledge of HIPAA regulations and NCQA standards
• Ability to work effectively within a team
• Firm computer skills including Microsoft Office
• Ability to multi-task and prioritize work

Requirements

• Performs pre-service and concurrent reviews of requested services within specified department timelines.
• In-Patient reviews include Acute Facilities and Skilled Nursing Facilities.
• Out-Patient reviews include service authorizations and home health care.
• Applies clinical knowledge for the interpretation and evaluation of clinical data to ensure compliance with established criteria.
• Reviews authorization requests for services according to adopted Plan and InterQual criteria.
• Reviews questionable cases with facility team members and the Medical Director to assess if care requested meets medical necessity criteria.
• Documents denial process and provides timely provider and member notification following specified timelines and department protocols.
• Initiates early discharge planning, incorporating transition of care plans, with facility team members and plan's primary care providers.
• Initiates and coordinates facility transfers, incorporating transition of care plans.
• Coordinates with appropriate state representatives and internal team(s) on member and provider appeals.
• Makes appropriate referrals to quality improvement, behavioral health, and complex case management.
• Completes retrospective chart reviews and pended claims reviews as requested.
• Maintains strong collaborative working relationships with specialty, ancillary, and primary care providers.
• Documents completely and accurately within an electronic clinical record.
• Provides education on the utilization management process to members and providers as requested.
• Ensures utilization management program compliance and successful reimbursements by understanding applicable contract terms.
• Participates in care management as a member of an interdisciplinary team.
• Maintains knowledge of pertinent regulatory and accrediting requirements.
• Maintains HIPAA standards and compliance with all state and federal regulations. Ensures confidentiality of protected health information.
• Performs special projects as assigned.

Benefits

• Medical, Vision and Dental Plans
• Tax-Advantage Savings Accounts (FSA & HSA)
• Life Insurance and Disability Insurance
• Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
• Employee Assistance Program
• 401k with company match
• Employee Resource Groups
• Employee Discount Program
• Learning and Development Opportunities
• And much more...