Catholic Health Initiatives Temporary Utilization Review Nurse (LPN or RN) in FEDERAL WAY, Washington

Temporary Utilization Review Nurse (LPN or RN)



The primary role of the Temporary Utilization

Management/Concurrent Review Nurse is to review and monitor members’

utilization of health care services with the goal of maintaining high quality

cost-effective care. All current members

are enrolled in Medicare Advantage plans.

The role includes providing the medical and utilization expertise necessary

to evaluate the appropriateness and efficiency of medical services and

procedures. This includes providing prior

authorizations, concurrent review, proactive discharge/transition planning,

appropriate referral to case management, and high dollar claims review. There is a heavy emphasis on concurrent review

and proactive transition planning for members in the hospital, skilled nursing

facility, and acute inpatient rehabilitation settings. This is an in office

based position.

Essential Duties and Responsibilities

  • Performs concurrent and

retrospective reviews on all facility (hospital, skilled nursing facility, and

acute rehabilitation) and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of

acutely and chronically ill patients with the objective of improving quality

outcomes and decreasing costs. Evaluates

and provides feedback to member’s providers regarding a member's discharge

plans and available covered services, including identifying alternative levels

of care that may be more appropriate.

  • As part of the hospital

prior authorization process, responsible for determining “observational” vs.

“acute inpatient” status.

  • Integral to the

concurrent review process, actively and proactively engages with member’s

providers in proactive discharge/transition planning.

  • Presents facility-patient

status updates and addresses barriers to discharge/transition at regularly held

concurrent review rounds.

  • Actively participates in

the notification processes that result from the clinical utilization reviews

with the facilities. Prepares CMS-compliant notification letters of NON-certified

and negotiated days within the established time frames. Reviews all NON-certification files for

correct documentation.

  • Maintains

accurate records of all communications.

  • Provides clinical

support to non-clinical Care Management Coordinators as relates to Prior

Authorization requests.

  • Monitors utilization

reports to assure compliance with reporting and turnaround times.

  • Addresses care issues

with Manager, Vice President and Chief Medical Officer/Medical Director as


  • Coordinates an

interdisciplinary approach to support continuity of care.

  • Provides utilization

management, transition coordination, discharge planning, and issuance of all

appropriate authorizations for covered services as needed for providers and members.

  • Coordinates

identification and reporting of potential high dollar/utilization cases to

reinsurer and finance department for appropriate reserve allocation.

  • Identifies and recommends opportunities for

cost savings and improving the quality of care across the continuum.

  • Clarifies health plan

medical benefits, policies and procedures for members, physicians, medical

office staff, contract providers, and outside agencies.

  • Responsible for the

early identification and assessment of members for potential inclusion in a

comprehensive case management program.

Refers members for case Management accordingly.

  • Assists in the

identification and reviewing of Potential Quality of Care concerns through

concurrent review. Provides backup for

Case Manager.

  • Work

as an interdisciplinary team member within Medical Management and across all departments.

  • Provide

back up for other members of the Medical Management team when needed.

  • Other

duties as assigned.


Education and Experience

  • Bachelor's

degree preferred.

  • Minimum

3 years clinical experience as RN or LPN required.

  • Minimum

5 years managed care or equivalent health plan experience preferred.

  • Demonstrated

experience in health plan utilization management, facility concurrent review

(hospital, skilled nursing facility, acute rehabilitation), discharge planning,

and transfer coordination required.

  • Medicare

Advantage experience preferred.

  • Experience

with InterQual or Milliman authorization criteria required.

  • Excellent

computer skills and ability to learn new systems required.

  • Strong attention to detail, organizational skills and interpersonal

skills required.

  • Demonstrated

ability to problem solve and manage professional relationships.

Certificates, Licenses and Registrations

  • RN or LPN with active Washington State unrestricted license required.

Multi-state license will be a plus

Job Nursing - LPN


Daily Schedule Days

Scheduled Hours per 2-week Pay Period 80

Weekends Required None

Req ID: 2017-R0130038