Concurrent Nurse Reviewer, Facility Utilization Review Unit

HMSA•Honolulu, HI

23h

About The Position

The Concurrent Nurse Reviewer, within the Facility Utilization Review Unit, is responsible for applying medical necessity criteria to concurrent review determinations. This role involves detailed clinical judgment to assess the appropriateness of inpatient hospital stays based on the member's clinical condition and established medical policies. The Nurse Reviewer must adhere to the requirements of various lines of business and accrediting bodies (CMS, NCQA, HSAG). Key responsibilities include promoting quality of care, cost-effective outcomes, preventing unnecessary hospitalizations, decreasing lengths of stay, ensuring appropriate quality of care during hospital stays, and consulting with Medical Directors on complex cases. The role also involves providing consultation and referral to Case Management or QUEST Integration programs, identifying and utilizing community resources, evaluating suspended claims for medical necessity and appropriateness, communicating information accurately to internal and external stakeholders, identifying members with specific needs for referral, and performing other assigned duties.

Requirements

Associates Degree in Nursing
Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN
Two (2) years clinical care experience or case management or related experience.
Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
Good typing skills
Strong organizational skills
Good communication skills both verbally and written
Multi-tasking skills
Critical thinking skills
Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
Currently licensed in Hawaii as an RN or LPN (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

Responsibilities

Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations.
Determines if inpatient hospital stays are medically appropriate for the member's clinical condition or require referral to a Medical Director for potential denial.
Follows each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admission.
Uses effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to promote improved quality of care and/or life, promote cost effective medical outcomes, prevent hospitalization when possible and appropriate, promote decreased lengths of hospital stays when appropriate, ensure the quality of care member is receiving during hospital stay is appropriate, and ensure appropriate levels of care are received by patients.
Consults with Medical Directors on potential quality issues encountered during review of medical records in situations when the complexity of the member's medical, surgical and/or pharmaceutical management is unclear and may require further review or intervention and follow up with attending physicians, hospitalists or other facility staff.
Provides appropriate consultation and referral to Case Management or QUEST Integration program as appropriate.
Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing each case to fully utilize all available inpatient and community resources.
Identifies cost savings and accurately records all communications and interventions.
Evaluates suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
Communicates timely, accurate information either verbally or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to internal MM staff, other internal departments (Claims Administration, Customer Relations, etc.), providers, members and other authorized persons.
Ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines for denied services.
Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed.
Identifies and refers quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
Performs all other miscellaneous responsibilities and duties as assigned or directed.