RN - Inpatient Licensed Utilization Review II - Nebraska Medicaid (PS34924)
Location: Omaha, Nebraska, United States
Requisition #: PS34924
Post Date: 1 day ago
Location: This position will allow you to work from your home office but you must reside in Nebraska or a surrounding state and be able to commute to a company office as needed. Company offices in Nebraska include Omaha, Lincoln, Kearney, Norfolk, and Scottsbluff.
Work Hours: 8am to 5pm, Monday - Friday.
The Licensed Utilization Review ll (In-patient review for WellCare Nebraska Medicaid) is responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff.
Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. Primary duties may include, but are not limited to:
- Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members' eligibility, benefits and contract.
- Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
- Applies clinical knowledge to work with facilities and providers for care-coordination.
- May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
- Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
- Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
- Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
- RN required; 2 years of acute clinical or utilization review experience; 1 year of managed care experience and knowledge of the medical management process; or any combination of education and experience, which would provide an equivalent background.
- Current active unrestricted RN license issued by the state where you reside required.
- Knowledge of Community Resources available in Nebraska.
- Knowledge of Milliman (MCG), Interqual, and/or other established medical review criteria.
- Proficient use of computer programs including MS Word and Excel.