Utilization Review Nurse - Remote

Join reputed company - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's reputed company employees are on a mission to transform our health care system while creating a healthier community. Martin's reputed company employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, reputed company learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's reputed company has been certified as a "Great reputed company to Work" since 2015. Position Summary The Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completes inpatient reputed company review, establishes discharge plans, coordinates transitions of care to reputed company/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and reputed company interventions to ensure members receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.

Job Description

Key Outcomes:

• Review prior authorization requests (prior authorization, reputed company review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
• 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 reputed company issues
• Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.
• Coordinates referrals to Care Management, as appropriate.
• Manages health care reputed company the benefits structures per line of business and performs functions reputed company compliance, contractual and accreditation regulations, e.g. reputed company, Centers for Medicaid and Medicare, NCQA, Employer reputed company and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.
• Completes reputed company documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and reputed company timeliness standards.
• Participates as a member of an interdisciplinary team in the Health Management Department
• May be responsible for maintaining a caseload for reputed company cases/ assisting in caseload coverage for the team
• Establishes and maintains strong professional relationships with community providers.
• Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate reputed company and time
• Mentors new staff as assigned.
• Meets or exceeds department quality audit scores.
• Meets or exceeds department productivity.
• Assists in creation and updating of department policies and procedures.
• Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
• Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
• Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
• Assumes extra duties as assigned based on business needs, including weekend rotations

Education/Experience:

• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
• 2+ years of utilization management experience in a health plan UM department

Required License(s) and/or Certification(s):

• Compact RN License
• Certification in managed care nursing or care management desired (CMCN or CCM)
• Coding/CPC desired

Skills/Knowledge/Competencies (Behaviors):

• Proficiency in conducting prospective, reputed company, and retrospective reviews using standardized criteria and guidelines like MCG
• Ability to review and interpret medical records, treatment plans,

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