Concurrent Nurse Reviewer - Facility Utilization Review Unit

HMSA•Honolulu, HI

3d•Hybrid

About The Position

The Concurrent Nurse Reviewer will be responsible for applying medical necessity criteria to concurrent review determinations within the Facility Utilization Review Unit. This role involves detailed clinical judgment to assess the appropriateness of inpatient hospital stays based on the member's clinical condition, and to determine if a referral to a Medical Director is necessary for potential denial. The Nurse Reviewer must adhere to the requirements of each line of business and accrediting bodies such as CMS, NCQA, and HSAG for inpatient admissions. Key responsibilities include utilizing effective relationship management, service coordination, resource management, education, and patient advocacy to promote improved quality of care, cost-effective outcomes, prevent unnecessary hospitalizations, decrease lengths of stay, ensure appropriate quality of care during hospital stays, and ensure patients receive appropriate levels of care. The role also involves consulting with Medical Directors on complex cases and following up with healthcare providers.

Requirements

Associates Degree in Nursing
Two 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.
Typing speed of 40 wpm
Strong organizational skills
Good communication skills: verbal and written
Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
Currently licensed in Hawaii as an RN or LPN

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.
Promotes improved quality of care and/or life.
Promotes cost effective medical outcomes.
Prevents hospitalization when possible and appropriate.
Promotes decreased lengths of hospital stays when appropriate.
Ensures the quality-of-care member is receiving during hospital stay is appropriate.
Ensures appropriate levels of care are received by patients.
Consults with Medical Directors on potential quality issues encountered during review of medical records.
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.