Utilization Review Nurse
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About The Position
The Department of Care Management at SUNY Downstate Health Sciences University is seeking a full-time Utilization Review Nurse / TH Utilization Review/Quality Assurance Senior Coordinator. The successful candidate will be responsible for completing and sending initial clinical reviews within 48-hours of admission for medical necessity and appropriate level of care to all applicable payors via Care Management Module, CarePort. Additionally, the candidate will complete and send every 3-days, continuous stay reviews for patients outside of their ELOS, due to changes in medical status in order to justify medical necessity for a continued stay. The role also involves performing precertification reviews to establish medical necessity, appropriateness of services, and compliance with regulatory standards, established medical policy, community standards, and the members plan documents. Furthermore, the candidate will perform concurrent and retrospective evaluation of inpatient hospitalizations to establish medical necessity, appropriateness of services, and discharge planning needs; coordinating with the medical team to ensure clinically appropriate determinations. The position requires applying clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, forwarding all cases that do not meet these policies and guidelines to the Medical Director. The candidate will also identify and suggest alternative solutions including appropriate levels of care delivery or need for negotiations when indicated, and identify, investigate, and report to the medical team possible quality of care issues discovered during concurrent or precertification reviews. Participation in clinical rounds when applicable, quality improvement projects, continuing education, and medical management programs as required is also expected. The candidate will provide consistent and accurate case documentation in EMR and act as a liaison to members, participants, providers of care, and when appropriate, to payors. Other duties may be assigned as needed.
