Utilization Review Nurse Jobs

About The Position

Requirements

• RN, LPN, LVN, CMA.
• 2+ years of clinical experience in a healthcare setting.
• Prior experience with HEDIS abstraction or utilization review strongly preferred.
• Florida unrestricted license
• BLS certification
• Computer literacy
• Knowledge of current professional nursing theory, practice, and techniques
• Knowledge of current nursing practices in an outpatient primary care setting
• Knowledge of assessment of patient needs and services
• Knowledge of current professional nursing and pharmaceutical products, Universal Precautions, and emergency situations
• Knowledge of basic pathophysiology of diseases commonly managed in Family Medicine
• Knowledge of the application of nursing techniques (example: Triage, blood pressure monitoring, glucose monitoring, etc.)
• Knowledge of patient teaching and education (example: self-blood pressure monitoring, nutrition instruction, diabetes self-care instruction)
• Knowledge of general patient care and treatment procedures, equipment, rules, regulations, and ethics
• Knowledge of Utilization Review Accreditation Commission (URAC) Policies and Procedures
• Knowledge of processing and obtaining prior authorizations
• Knowledge of making observations of general physical condition and needs of patients and when to confer with a physician about the emotional or physical condition of a patient
• Knowledge of the principles of aseptic and sterile techniques and infection control techniques
• Knowledge of the techniques of administration of common medications, including immunizations, inoculations, and allergy injections using sterile technique, and knowledge of the side effects of these medications
• Knowledge of state and federal drug control laws, rules, and regulations
• Knowledge of emergency techniques and procedures
• Knowledge of common medical supplies and equipment
• Excellent interpersonal, communication and leadership skills
• Ability to demonstrate priority-setting and ability to work in a complex environment
• Ability to function with a high degree of independence and collaboration with other health care providers
• Commitment to service, quality, and departmental core values

Nice To Haves

• Prior experience with HEDIS abstraction or utilization review

Responsibilities

• Review medical records and clinical data for HEDIS-specific measures.
• Abstract and input accurate clinical data from electronic health records (EHRs) into reporting tools.
• Identify and report documentation deficiencies or care gaps.
• Collaborate with providers, coders, and clinical teams to ensure proper documentation and follow-up.
• Assist in the coordination and execution of the annual HEDIS data collection cycle.
• Maintain knowledge of current HEDIS specifications and regulatory updates.
• Support audits and internal quality improvement initiatives related to clinical outcomes.
• Ensure HIPAA compliance and confidentiality of patient information.
• Assess, identify problems, plan goals, monitor and evaluate patient plans, and develop strategies that meet the patients immediate and long-term goals.
• Work closely with PCP to manage patient “care items” which could include; medication refills per protocol, lab triage, document management, management of durable medical equipment (i.e. Glucometer, test strips, lancets), prior authorizations of needed medications or other services.
• Use patient data to track and schedule follow up appointments.
• Provide proactive utilization management for patients with high risk needs.
• Assist patients in obtaining appropriate medications and medical supplies and equipment, including coordination of pharmaceutical patient assistance programs.
• Participate in quality improvement, quality assurance and innovation activities to ensure optimal level of care delivery.
• Ensure all HEDIS measures have been met for those assigned patients and all care gaps have been identified.
• Assist in the coordination of warm hand-offs or “transfer of trust” between care team, pharmacy or other support services during the office visit.
• Carry out other duties as assigned by the DMC.
• Be familiar with CFHC’s program philosophies, goals and objectives.
• Be cognizant of and comply with all CFHC’s policies and procedures, as well as state and federal regulations.
• Be competent in performing the duties of a nurse.
• Understand the requirements of CFHC’s Exposure Control Plan.
• Personally, utilize universal precautions when practicing in a clinical setting.
• Participate in staff outreach and off-site health care programs as requested by the DMC, ACMO, CMO, or CEO.
• Represent CFHC in the community.
• Report as needed to DMC and any pertinent information or situations that impact on patient care or CFHC liability.
• Attend and participate in mandatory CFHC meetings (Center Specific meetings, Corporate meetings, and other meetings as designated by the DMC, ACMO, CMO, or CEO).
• Demonstrate ability to work cooperatively with other members of the clinical team.
• Be supportive of coworkers.
• Maintain a neat and professional appearance at all times.
• Carry out any other activities deemed appropriate by the DMC, CMO, or CEO.

Benefits

• Competitive Salary
• Federal Student Loan Forgiveness: PSLF – 10-year commitment, 120 loan payments and at the end of the commitment, the remaining loan is forgiven
• Excellent medical, dental, vision, and pharmacy benefits
• Employer Paid Long-Term Disability Insurance
• Employer Paid Life Insurance equivalent to 1x your annual salary
• Voluntary Short-Term Disability, additional Life and Dependent Life Insurance are available
• Malpractice Insurance
• Paid Time Off (PTO) – 4.4 weeks per year pro-rated
• Holidays (9.5 paid holidays per year)
• Paid Birthday Holiday
• CME Reimbursement
• 401k Retirement Plan after 60 days of service (w/matching contributions)