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
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
accurate records of all communications.
- Provides clinical
support to non-clinical Care Management Coordinators as relates to Prior
- 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.
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
as an interdisciplinary team member within Medical Management and across all departments.
back up for other members of the Medical Management team when needed.
duties as assigned.
Education and Experience
3 years clinical experience as RN or LPN required.
5 years managed care or equivalent health plan experience preferred.
experience in health plan utilization management, facility concurrent review
(hospital, skilled nursing facility, acute rehabilitation), discharge planning,
and transfer coordination required.
Advantage experience preferred.
with InterQual or Milliman authorization criteria required.
computer skills and ability to learn new systems required.
- Strong attention to detail, organizational skills and interpersonal
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
Primary Location WASHINGTON-FEDERAL WAY-FEDERAL WAY-HERON BLDG
Daily Schedule Days
Scheduled Hours per 2-week Pay Period 80
Weekends Required None
Req ID: 2017-R0130038