- Purpose: This position consistently applies the utilization management process as required by CMS including the use of designated criteria for primary review. Incorporates into the utilization management process the ability to access and interpret clinical information against the designated review criteria to reach status determinations. Has the current knowledge of applicable regulations and laws pertaining to Hometown Health plans; including CMS and NCQA requirements. Working with the interdisciplinary team, medical necessity evaluations are made based on nationally recognized criteria for all prior authorizations, admissions and concurrent reviews and in coordination with the health plan Medical Director or Chief Medical Officer, ensuring that the care and services provided are medically necessary, cost and clinically effective, delivered efficiently and timely, and at the appropriate level of care to meet requirements and established financial/performance benchmarks for Hometown Health. Incumbent will work with the Utilization Management team to ensure that clinical denials have accurate tracking and are reported to Utilization Management leadership. Discharge planning assistance collaborative with hospital staff to channel members to contracted providers and maintain services with current providers when needed to prevent member disruption. Coordinate with other team members to ensure the members experience exceeds expectations. Identifies issues and recommends process improvement strategies to optimize member care. Nature and Scope: Applies medical necessity guidelines to complete utilization review procedures-prospective and concurrent- review to determine medical necessity for facilities and services to ensure the member is receiving quality cost effective care in the appropriate setting. Use nationally recognized, evidence-based guidelines approved by medical staff to review referrals and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, and coverage determinations. Assist in gathering of clinical information and managing denials. Coordinates services to avoid under or over utilization of resources. Redirects members to in network providers and facilities when appropriate. Promote positive outcomes (quality) and the utilization of resources in an efficient and cost-effective manner within the benefit structure. Facilitates or participates in interdisciplinary team meetings to assure appropriate level care and resource utilization. Consults with physicians and facility case managers regarding the appropriate level of care or admission status when criteria are not met for correct level of care for inpatient, observation or continued stay. Refers referrals to Medical Director or external review service according to policy and documents the referral. Identifies and documents avoidable days, authorizations and denials. This position also provides information to the Hometown Health care team (RN, physicians, case manager, social worker, and transitional care navigators) as needed, as well as the facility care team when necessary to ensure the appropriate and timely disposition of the client. The Utilization Management RN, documents all chart and phone reviews, identifies and communicates potentially avoidable days, and quality indicators (such as readmissions or issues).This position will be required to work a flexible schedule that may include weekends to provide coverage for the department as needed.The Utilization Management RN will follow the Hometown Health policies and procedures. The scope includes potential for cross training within the utilization roles to cover for departmental vacations, illness and vacancies. This position does not provide patient care. This position makes no clinical adverse determinations.Knowledge, Skills & Abilities:
- Strong interpersonal communication skills both written and verbal.
- The ability to understand and resolve complex problems in a timely and effective manner using critical thinking skills.
- The ability to keep current with new developments and acquire the needed knowledge for the position in order to keep skill sets up to date.
- The ability to work under stress and to meet deadlines.
- Knowledge of applicable regulatory requirements and community resources.
- Documents all medical necessity determinations, member and provider contacts, and medical necessity criteria in utilization review system.
- Knowledge of group and individual health insurance plans, Medicare Advantage Plans, Centers for Medicare and Medicaid Services (CMS) and Division of Insurance regulations and NCQA accreditation requirements.May be responsible for other duties as assigned. This position may be virtual or remote.This position does not provide patient care
Requirements - Required and/or Preferred Name Description
Ability to read, write, speak, and understand English sufficiently to perform job duties safely and effectively. Bachelor of Science in Nursing Degree preferred.
Minimum two years of clinical experience working in an in-patient or outpatient setting required. Two to three years of previous managed care utilization management or case management, experience recommended. License(s): Current and unrestricted State of Nevada Registered Nurse license and licensure from State in which they have residency required.
Certification(s): Utilization Management Certification desirable. Computer / Typing: Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, Teams, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc. Disclaimer: The foregoing description is not intended to be, and should not be construed as, an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.
It is intended to be an accurate reflection of the general nature and level of the job.
Day shift · 8-5