Nurse, Concurrent Review

HealthHelp•Houston, TX

16h•Remote

About The Position

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria. This includes admission reviews, continued stay reviews, and transitional care reviews for facilities like Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Long-Term Acute Care Hospitals. The role involves related follow-up activities and documentation updates. The nurse will engage in clinical collaboration with attending physicians, hospitalists, and care teams to gather clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions. The position requires the ability to communicate clinical rationale effectively during real-time interactions and to facilitate the resolution of escalated cases. Cases may be referred to a Physician Reviewer or a Specialty Program Medical Director per guidelines, and the nurse will assist these individuals as necessary to ensure compliance with review timeframes. Maintaining written documentation according to policy, understanding regulations, accreditation requirements, and payer-specific guidelines are crucial. The nurse will apply InterQual level-of-care criteria and applicable medical policies to inpatient review determinations, adhering to all HIPAA, state, and federal regulations. Compliance with URAC & NCQA standards or other requisite regulating bodies is expected. The role involves ensuring consistency in policy implementation, staying current with regulation changes, and functioning as a subject matter expert for compliance initiatives. Collecting and entering confidential information with the highest level of confidentiality is paramount. The nurse will perform clinical intake and review cases according to policies and procedures, including those for expedited turnaround times. Availability to support concurrent review coverage requirements, potentially including non-standard business hours, weekends, or holidays, is necessary based on client contractual obligations and regulatory review timeframes. The ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines is essential. Quality issues will be identified and referred to UM Leadership. Collaboration with client personnel to resolve customer concerns and providing quality customer service through interactions with providers and staff are key aspects of the role. The nurse will create, encourage, and support an environment that fosters teamwork, respect, diversity, and cooperation. Promoting a business focus that demonstrates an understanding of the company’s vision, mission, and strategy is also expected. Participation in the HealthHelp Quality Management Program is required, along with performing other related duties and projects as assigned.

Requirements

RN graduate from an accredited school of nursing (BSN preferred)
Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
Two (2) years of experience in an acute care setting, required
Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
Good organizational and time management skills
Excellent written and verbal communication skills
Ability to utilize critical thinking skills
Highly motivated, self-starter who can work efficiently and independently, or as a team member

Nice To Haves

Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
Willingness to complete and maintain InterQual certification and ongoing competency requirements
Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
Knowledge of insurance terminology
Experience working with state and federal regulatory and compliance standards, preferred

Responsibilities

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria.
Conducts admission reviews, continued stay reviews, and transitional care reviews.
Performs related follow-up activities and documentation updates.
Engages in clinical collaboration with attending physicians, hospitalists, and care teams.
Communicates clinical rationale to attending physicians, hospitalists, and facility staff.
Facilitates resolution of escalated cases.
Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines.
Assists Physician Reviewers and Medical Directors to ensure compliance with review timeframes.
Maintains written documentation according to policy.
Applies InterQual level-of-care criteria and applicable medical policies to inpatient review determinations.
Adheres to all HIPAA, state, and federal regulations.
Complies with URAC & NCQA standards or other requisite regulating bodies.
Ensures consistency in implementation of policy, procedure, and regulatory requirements.
Keeps current with regulation changes.
Functions as subject matter expert to support Compliance Department initiatives and updates.
Collects and enters confidential information ensuring the highest level of confidentiality.
Performs clinical intake and reviews cases according to policies and procedures.
Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays.
Performs multiple tasks simultaneously, prioritizes projects, works independently under pressure, and meets critical deadlines.
Identifies and refers quality issues to UM Leadership.
Collaborates with client personnel to resolve customer concerns.
Provides quality customer service through interaction with providers, administrative staff, and others.
Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation.
Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
Participates in the HealthHelp Quality Management Program, as required.
Performs other related duties and projects as assigned to meet business needs.