The primary role of the Utilization Review (UR) Nurse is to provide clinical support to the Utilization Management Department and Medical Director to assure that our members receive all appropriate medical services in compliance with medical and regulatory guidelines. Responsibilities include, but are not limited to, review and authorization of Outpatient Services, review of requests for pre-authorization of elective admission and procedures, inpatient admission review, review of continuing stay and discharge planning and coordination of care and services of select member populations with common chronic conditions. In all areas, the UR Nurse is charged with managing the delivery of care in an effective, professional and compassionate manner.
Review and evaluate all requests for elective inpatient admission
Authorizes those inpatient requests that meet the health plan s approved UM criteria and policies in the Clinical Services P&P Manual
Identify on a daily basis all MLTC members who are currently hospitalized
Conduct initial inpatient review and determine the appropriateness of admission, anticipated length of stay and potential discharge needs
Prioritize the review of patients according to the relevant Clinical Services Policy and Procedures
Accept telephonic and faxed reviews
Document the inpatient review in the computer system including diagnosis, procedures, attending physician, treatment plan, anticipated length of stay, and the Interqual Criteria used to justify continued stay
Perform concurrent review and enter information in the computer system in a timely manner Assess and coordinate referrals for inter-hospital transfers and specialty care
Appropriately and expeditiously refer cases to the Medical Director, process Medical Director s decision in the computer system
Generate Approval and Denial letters based on Medical Director s determination
Expeditiously alert providers by phone of denials
Appropriately refer cases to re-insurer in a timely manner
Actively participate in the discharge planning process with the facility discharge planner to ensure timely discharge, appropriate follow up and continuity of care
Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation
Refer cases with quality of care concerns to the Medical Director and Quality Improvement Dept.
Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer.
Tasks specific to Outpatient Services assignment (Specialist Authorization and Pre-certification of Ambulatory procedures)
Review and evaluate all requests for office visits, home care, outpatient procedures, ambulatory surgery and transportation according to MLTC's UM guidelines and the standards specified in the MLTC Utilization Manual & Accept telephonic and faxed reviews
Authorizes those requests that meet the health plan s approved UM criteria and the policies in the Clinical Services P&P Manual.& Appropriately document the review in the computer system including: diagnoses, procedures, specialists, treatment plan, and the Interqual Criteria used to justify the approval of request
Appropriately and expeditiously, refer cases to the Medical Director Process
Medical Director s decision in the computer system
Generate Approval and Denial letters based on Medical Director s determination.
Expeditiously alert provider of phone denials
Refer cases with quality concerns to the Medical Director and Quality Improvement Dept.
Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer
Assist members in accessing services, including making appointments for members when appropriate and providing patient teaching and support to facility compliance with treatment.
Must comply with all MLTC policies and procedures
Perform follow-up phone calls to facilitate obtaining of documents for any member visit or admission to Facilities, ER, Hospital
Maintain confidentiality of all member information in compliance with HIPAA requirements Accept and perform
Additional duties as assigned within the scope of Nursing knowledge and skills
Must have 1-3 years experience (MLTC preferred/UM and/or CM experience is a plus
ASN (minimum)/BSN Preferred
Must know EMR
NYS RN License
This position is 9am-5pm/in-office position with no remote work available.
Associated topics: care unit, domiciliary, infusion, maternal, mhb, neonatal, nurse rn, psychiatric, staff nurse, transitional
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.