Responsible to the Manager of Utilization Management (UM) for general, pre-certification, concurrent and/or retrospective review of inpatient and/or outpatient services.
The Concurrent Review Nurse evaluates inpatient treatment and clinical progress of members admitted to acute and sub-acute care facilities. Works closely with the departmental management to impact the treatment plan and identify treatment plan alternatives.
ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following. Other duties may be assigned.
- Regularly and dependably reports to work as scheduled. Follows all Company policies and procedures, including but not limited to personnel policies, safety policies and operational policies as communicated by management.
- Follows all Department policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements and performance requirements as communicated by management.
- In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member and client information as specified by Company confidentiality policies and procedures.
- Represents the Company in a professional manner at all times when dealing with both internal and external customers.
- Conducts telephonic or on-site concurrent review for all assigned acute and sub-acute admissions. Utilizes designated criteria along with clinical knowledge to make authorization decisions and assists the Medical Director with review determinations.
- Evaluates all requests for services to determine financial liability including the collection of information regarding subrogation and COB.
- Interacts with medical director using medical knowledge and clinical experience; evaluates plan of care to determine patient is receiving the best care in the best setting; updates cases in the system with treatment plans, objectives, results and next steps.
- Initiates and maintains direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Applies appropriate benefit information to determine if services are a covered benefit.Applies medical knowledge and experience to authorize outpatient services as an alternative to hospitalization when appropriate.
- Arranges for transfer to in-network care when appropriate.Anticipates discharge planning early in acute admissions to discharge to appropriate level of care.Identify cases appropriate for care management and makes appropriate referrals; works effectively with Care Management to coordinate case transition when needed.Identifies potential quality of care issues.Meets regulatory standards for decision turnaround times and required Medicare Notices.Provides superior customer service to internal and external customers.
EDUCATION AND/OR EXPERIENCE: Graduate from an accredited school of nursing. Three to Five (3 – 5) years of clinical experience in an acute care facility; or a combination of acute and clinic experience. Managed care experience; and Payer experience and/or experience using InterQual or MCG, preferred.