Registered Nurse, Utilization Review

Nascentia Health•Syracuse, NY

12h•Onsite

About The Position

The Utilization Review Nurse assists the utilization review process taking on various tasks including data collection of demographic, claim and medical information; analysis; and outcomes reporting. Utilizes standards of care, evidence based practices, Medicare and Medicaid and organizational coverage guidelines to assure members receive high quality, cost efficient health care and services to meet their long term home and community based needs. Performs utilization review in accordance with all state mandated regulations.

Requirements

Current NYS RN licensure, BSN preferred.
Five or more years of home health care or long term care experience strongly preferred.
Three or more years of utilization management or quality improvement experience preferred.
Excellent relationship management skills
Demonstrated ability to problem solve complex, multifaceted situations
Successfully manage conflict and negotiate a win win solution
Strong organizational, prioritizing and delegation skills
Abstract thinking
Strong communication skills written and verbal
Advocacy focused
Ability to be non-judgmental
Computer literacy with Microsoft office products
Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication
Ability to sit 90% of the day
Frequent sitting, standing, walking
Pushing, pulling, reaching, kneeling
Category III

Responsibilities

Assist with the review of member usage patterns for medical necessity and appropriateness.
Performs continuing review of medical records and supporting documentation for medical necessity where appropriate.
Tracks and analyzes service utilization patterns monthly and compares to regional benchmarks
Reviews appeals and provides notice of determination.
Receives and responds to Office of Temporary and Disability Assistance (OTDA) notifications of Fair Hearings
Prepares for and attends Fair Hearings.
Assist with the development of coverage policy guidelines for MLTC services.
Participates in interdisciplinary collaboration with professional staff.
Creates and facilitates educational programs.
Identifies and collaborates with UR Manager on individual cases
Identifies and collaborates with UR Manager on trends in usage patterns.
Process Notice of Action letters
Performs concurrent, prior service authorizations and retrospective reviews
Analyze per member per month (PMPM) data
Other duties as assigned