Utilization Review RN

UHS•Reno, NV

16h

About The Position

Prominence Health is a value-based care organization that connects affiliated health systems and independent providers to strengthen partnerships, advance market opportunities, and improve outcomes for patients and members. Founded in 1993 as a health maintenance organization, it was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. It serves members, physicians, and health systems through Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. The Utilization Review Nurse (initial clinical reviewer) reviews and evaluates requests for medical services for appropriateness against established criteria and published medical evidence. Using clinical and operational knowledge, the nurse assesses needs and coordinates resources within and outside the benefit plan to promote optimal clinical and financial outcomes. The reviewer may assist with notifications of non-certifications but does not issue non-certifications. Cases requiring additional expertise are referred or presented to a Medical Director or other appropriately qualified professional. The role also measures and reviews performance outcomes, proposes and implements improvement processes and system enhancements, identifies appropriate resources, manages cases, maintains accurate records, and provides timely verbal and written reports as directed. The position requires an active, current, valid, unrestricted professional license or certification recognized in the applicable jurisdiction where the organization provides utilization management services, including Nevada, Texas, and/or Florida.

Requirements

Graduation from an accredited nursing education program.
Current, active, valid, unrestricted license recognized in the relevant jurisdiction to practice in Nevada, Florida, and/or Texas as an RN, LPN, or LVN.
Must be able to practice as a health professional in a U.S. state or territory.
At least three years of Utilization Review or Case Management experience.
Recent working knowledge, within the past three years, of InterQual criteria and/or Milliman Care Guidelines.
At least three years of clinical medical/surgical nursing practice in a hospital setting.
Ability to communicate expertly in English, verbally and in writing.
Attention to detail and ability to prioritize, problem-solve, and multitask.
Ability to analyze and interpret data quickly and write reports using standard medical terminology.
Experience executing strategies and organizing and prioritizing multiple projects and relationships with key stakeholders and program implementers.
Written and oral communication skills, including large- and small-group presentations, group facilitation, and training.
Ability to influence others and collaborate with key partners to achieve positive results.
Ability to use relevant tools such as word processing, spreadsheet, email, database, and voicemail programs.
Empathetic, caring, compassionate listening skills.
Excellent computer skills.
Ability to work with a diverse multicultural and socioeconomic population.
Familiarity with healthcare delivery and/or health insurance programs.
Any permitted license restriction must, as determined by the Medical Director or Clinical Director, not affect the professional’s ability to fulfill the initial clinical reviewer role.

Nice To Haves

Bachelor’s degree from an accredited nursing education program.
Advanced degree such as an MBA, MPH, or master’s in nursing, or advanced focused training.
Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ) certification.
Bilingual ability in English and Spanish.

Responsibilities

Review and evaluate clinical cases and medical-service requests for appropriateness using established criteria and published medical evidence.
Be available to non-clinical administrative staff during their initial screening process.
Assess member needs and coordinate resources within and outside the benefit plan to promote optimal clinical and financial outcomes.
Refer or consult with a Medical Director or other appropriately qualified professional when cases require additional expertise.
Assist with notification processes for non-certifications; initial clinical reviewers do not issue non-certifications.
Measure and review performance outcomes and propose and implement improvement processes and system enhancements.
Identify appropriate resources and demonstrate knowledge in managing each case.
Maintain accurate records and provide timely verbal and written reports as directed.