Utilization Review Nurse
About The Position
This role involves participating in the development and ongoing implementation of Quality Management (QM) Work Plan activities. The primary goal is to improve quality products and services by using measurement and analysis to process, evaluate, and make recommendations to meet QM objectives. The nurse will review documentation, evaluate potential Quality of Care issues based on clinical policies and benefit determinations, and consider all documented system information as well as additional records to develop determinations or recommendations. This requires navigating multiple IT platforms and potentially contacting providers, vendors, or internal departments for additional information. The role also involves evaluating documentation to determine compliance with clinical policy, regulatory, and accreditation guidelines, and interpreting data from clinical records to apply appropriate clinical criteria and policies. The nurse will work on Potential Quality of Care cases across all lines of business (Commercial and Medicare), independently coordinating clinical resolution with internal/external clinician support. They will process and evaluate complex data and information sets, convert data analysis results into meaningful business information, and prepare QM documents based on interpretation and application of business requirements. Documentation of QM activities is crucial to demonstrate compliance. The role also assists in the development and implementation of QM projects and activities and is accountable for completing and implementing QM Work Plan Activities.
Requirements
- 3+ years of experience as an RN
- 1+ years of inpatient hospital experience
- Registered Nurse in state of residence
- Must have prior authorization utilization experience
- Able to work in multiple IT platforms/systems
- MUST HAVE MEDCOMPASS or ASSURECARE exp.
- MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
- MUST HAVE UM experience, inpatient utilization management review.
- MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
- MUST HAVE 6 months of Prior Authorization.
Nice To Haves
- pref. knowledge of Milliman/MCG
Responsibilities
- Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
- Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
- Data gathering requires navigation through multiple system applications.
- Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
- Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
- Responsible for the review and evaluation of clinical information and documentation.
- Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
- Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
- Independently coordinates the clinical resolution with internal/external clinician support as required.
- Processes and evaluates complex data and information sets.
- Converts the results of data analysis into meaningful business information and reaches conclusions about the data.
- Prepares and completes QM documents based on interpretation and application of business requirements.
- Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements.
- Assists in the development and implementation of QM projects and activities.
- Accountable for completing and implementation of QM Work Plan Activities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
