Utilization Management Pre Service Review Nurse Jobs

Maniilaq Association isa P.L. 93-638 Native/Indian Preference/EEO Employer

Program: Nursing Status: Exempt

Housing Priority: 3 Covered: Yes

The Utilization Management Nurse (UMN) is responsible for performing Utilization Review and managing risk, coordinates and facilitates with departmental staff on Durable Medical Equipment (DME), and pharmacy prior authorizations. THE UMN works with the medical treatment and case management team in the coordination of patient care including the development of new operational changes and new services to ensure compliance and risk mitigation. The UMN will use a process that includes screening and case finding, comprehensive multidimensional assessment, connection with available resources, implementation of the plan and ongoing monitoring and re-assessment/follow-up. The UMN assists with the Quality and Case Management programs and,coordinates the IPC4 program. This position reports directly to the Chief Nursing Officer or designee.

• Coordinates the IPC4 process in Medicare/Medicaid and private insurances.
• Assists in revenue procurement by:making sure insurance approvals are completed correctly with no penalty; helping to identify alternate resources of funding such as VA, Denali Kid Care, Medicare, and Medicaid; and monitoring the appeal process when claims are denied.
• Chairs Quarterly Utilization Review Committee meetings to improve utilization of resources and improve patient care.
• Submits Quarterly reports to CMO and CNO for Board of Director meetings.
• Works closely with Coders and Billers to insure accurate, timely billing information.
• Completes Utilization Review processes as assigned.
• Oversees development and maintenance of a resource database of Federal, State, community, and institutional resources.
• Assists in arranging team conferences and networks for relationship building and resource development with village leaders, Community Health Aides/Practitioners, MHC Medical Staff, MHC Nursing Staff, private insurance contacts, Medicaid/Medicare contacts, ANMC Providers, and the CM/SC/UR Team.
• Participates on improvement projects as assigned.
• Participates in Medicaid Task Force committee through Alaska Native Health Board.
• Completes Quality Improvement, Quality Assurance and Performance Improvement projects and tasks as assigned.
• Utilizes team building, problem solving skills and lean principles in the on-going quality improvement initiatives.
• Identify, assess, and monitorpotential clinical, operational, and compliance risks within the Utilization Review and Case Management programs.
• Report and documentincidents, near-misses, and adverse events in accordance with organizational policy and regulatory standards.
• Participate in root cause analysesand collaborate with leadership to implement corrective action plans to mitigate future risks.
• Collaborate with the Risk Management teamto review, update, and communicate policies and procedures relevant to utilization review and patient care coordination.
• Educate clinical and administrative staffon risk awareness, safety protocols, and compliance requirements.
• Coordinate and facilitate prior authorizations for DME by collaborating with patients, clinical staff and providers to ensure clients’ needs are met.
• Collaborate with providers and pharmacist process prior authorizations for specialized high-cost medications; monitor appeal process if claims are denied.

Current licensure as a RN with at least two years of Case Management, Utilization Review, Discharge Planning or Quality Improvement experience preferred. Knowledge of acute and chronic illnesses, specialty clinic procedures, and community health nursing. Must be able to pass the core competencies assigned to this position and maintain the educational requirements of the program. Ability to utilize various computer programs, including Cerner and Microsoft Office. Demonstrates a wide theory base in order to interact in an effective manner with physicians, health team members, community agencies, and clients/families with diverse opinions, values, and religious and cultural ideals. Ability to work autonomously with little direction and be directly accountable for practice. Knowledge of and experience working with all regulatory, state, and federal agencies.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be considered an exhaustive list of all responsibilities, duties and skills required of personnel in this job, and the employer reserves the right to revise or change this description. This description does not constitute a written or implied contract of employment. To perform this job successfully, an individual must be able to satisfactorily perform each of the above essential duties and meet physical demands. Reasonable accommodations may be made to enable individuals with disabilities to meet those conditions.