Remote Utilization Review Nurse – Flexible 4 or 5 Day Schedule, Saturday Required

Martin’s Point Health Care • Portland, ME

2d • Remote

About The Position

The Utilization Review Nurse is responsible for ensuring the receipt of high quality, cost-efficient medical outcomes for enrollees needing inpatient/outpatient authorizations. This role involves reviewing prior authorization requests, notification of emergent hospital admissions, completing concurrent reviews, establishing discharge plans, coordinating transitions of care, making referrals for care management programs, and performing medical necessity reviews for retrospective authorization requests and claims disputes. The nurse will use governmental policies and clinical guidelines to guide reviews and employ relationship management, coordination of services, resource management, education, and patient advocacy to ensure members receive the appropriate level of care and to prevent or reduce hospital admissions where appropriate.

Requirements

• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting.
• Utilization management experience in a health plan UM department.
• Compact RN License.
• Maintains current licensure and practices within scope of license for current state of residence.
• Maintains knowledge of Scope of Nursing Practice in states where licensed.
• Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately.
• Ability to analyze data metrics, outcomes, and trends.
• Excellent interpersonal, verbal, and written communication skills.
• Critical thinking: can identify root causes and understands coordination of medical and clinical information.
• Ability to prioritize time and tasks efficiently and effectively.
• Ability to manage multiple demands.
• Ability to function independently.
• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

Nice To Haves

• Certification in managed care nursing or care management desired (CMCN or CCM).

Responsibilities

• Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity, referring to the Medical Director as needed.
• Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
• Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement-related issues.
• Collaborate with team members, MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources.
• Communicate with in- and out-of-network hospitals, post-acute care facilities, other providers, and internal departments to authorize services, establish discharge plans, and coordinate transitions of care.
• Coordinate referrals to Care Management as appropriate.
• Manage healthcare within the benefits structures per line of business and perform functions within compliance, contractual, and accreditation regulations.
• Maintain knowledge of applicable regulatory guidelines.
• Complete all documentation of reviews and decisions in appropriate systems according to process/compliance requirements and within timeliness standards.
• Participate as a member of an interdisciplinary team in the Health Management Department.
• May be responsible for maintaining a caseload for concurrent cases or assisting in caseload coverage for the team.
• Establish and maintain strong professional relationships with community providers.
• Act as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time.
• Mentor new staff as assigned.
• Maintain quality audit scores within department standards.
• Maintain productivity within department standards.
• Assist in the creation and updating of department policies and procedures.
• Participate in quality initiatives, committees, work groups, projects, and process improvements.
• Participate in the review and analysis of population data and metrics.
• Demonstrate flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
• Assume extra duties as assigned based on business needs, including weekend rotations.

Benefits

• Organizational culture of trust and respect
• Values: taking care of ourselves and others, continuous learning, helping each other, and having fun
• Certified as a "Great Place to Work" since 2015

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed