Utilization Management Nurse Reviewer

Job Description

Utilization Management Nurse Reviewer

About the Position

HealthSmart Management Services Organization, Inc. is looking for a full-time qualified UM Nurse Reviewer who will be responsible for reviewing and processing Authorization requests of medical services from health professions, clinical facilities and ancillary providers. Qualified candidate will coordinate with Providers and their office designees as a resource for their various inquiries and needs.

Experience & Education Requirements:

High School Graduate or equivalent required.

Current unrestricted RN or LVN License to practice in the State of California.

Minimum of three (3) years current clinical experience preferred.

IPA and Managed care experience preferred.

Knowledge of medical criteria for Apollo, MCG and Medicare/Medi-Cal guidelines.

Excellent telephone skills required.

Computer experience desirable.

Excellent interpersonal skills.

ICD 10- CM and CPT/ HCPCS Medical Coding

Strong problem solving, organizational skills and time management skills with the ability to work in a fast-paced environment.

ACCOUNTABILITY/DUTIES/RESPONSIBILITIES:

Accurate processing of referrals for assigned medical group(s), which includes:

Eligibility verification

Receives reviews, verifies and processes requests for referrals, diagnostic testing, inpatient admissions, outpatient procedures/testing, emergency room notification, home health care services, and durable medical equipment and supplies via telephone, fax or on-line portal.

Reviewing all adverse decisions for accuracy of member-specific information and appropriateness of lay language regarding the Physician Reviewer’s decision. Works closely with Denial Coordinator, Physician Reviewer, and Director of Utilization Management for use of criteria/guidelines

Utilization of mandatory UM Nurse documentation to include Hierarchy of criteria used to either make decision (based on IPA Matrix) or to assist Physician Reviewers in criteria review.

Reviews for potential CCS eligible conditions and notify appropriate CCS designated staff for processing.

Review of prior activity

Ensure coordination of services, where necessary

Ensure timeliness of notification to providers (and members, when indicated)

Timely processing of referrals for assigned medical group(s) according to timeliness chart.

Maintain coordination of services between health plans, CCS, Case Management, Linked services, etc.

Maintain professional interaction with Medical Directors, Physician Reviewers, IPA Physicians and staff, Nurse/Case Managers for Outpatient coordination of Case Management cases, Fellow coworkers, etc.

Maintain compliance with UM Plan and Policy and Procedures as related to your role as a Nurse Reviewer

Maintain compliance with HIPAA rules and regulations.

Other duties, as identified/assigned.

WORK ENVIRONMENT, PHYSICAL DEMANDS AND MENTAL DEMANDS:

· Typical office environment with no unusual hazards.

· Repetitive movements with use of keyboard, mouse, and phone.

· Constant sitting while using the computer terminal.

· Constant use of sight abilities while reviewing documents.

· Regularly speak and listen in person, telephone, and remote meetings

· Constant mental alertness must possess planning/organizing skills and must be able to work under deadlines.

· Occasionally required to stand, walk, stoop, kneel, bend, crouch and lift up to but not more than 10 pounds.

HealthSmart Management Service Organization, Inc provides a full suite of benefits:

· Generous contribution toward individual and dependent Medical and Dental Insurance.

· Vision Insurance.

· Supplemental Short Term and Long-Term Disability Insurance.

· Voluntary Life Insurance for subscriber and dependents.

· Flexible Spending Account.

· Generous Paid Time Off plan.

· Paid Holidays.

· Flexible Spending Accounts.

· Discretionary Bonuses.Company Description

HealthSmart MSO, Inc. (HSMSO) is a management service organization serving the needs of providers in a managed care setting. Our Vision is to motivate, facilitate, and create opportunities for our client’s and team. HealthSmart MSO’s goal is to ensure its Managed IPA’s, Medical Groups, Hospitals and Physician Practices have a coordinated cost effective delivery system where quality services to members and physicians are achieved. Together, members and providers work toward a common goal of wellness and preventive medicine. As needs arise, physicians and their members feel comfortable knowing that they will receive care from the most dedicated and friendly managed care team.

Full-time