The primary responsibility of this position is to manage utilization, prior authorization, and perform clinical review of hospitalized members to verify level of care, frequency of utilization, placement into appropriate care or service through discharge planning and facilitate cost alternatives to requested services without compromising quality. The nurse will work directly with the QI Medical Director and UM Medical Director to implement approved AC Quest, ACA, ACAP coverage criteria and utilization review to appropriately provide resources and covered services to AC members.
Primary Duties and Responsibilities:
Required Competencies and Qualifications:
- Review and authorize medical necessity reviews for prior authorization of select out patient procedures and all elective inpatient admissions
- Review referrals, member eligibility, benefit coverage, and member qualification to AC approved criteria.
- Interface with Providers (physicians, DME, and other providers) to discuss issues and concerns with PA requests process and facilitate timely access to medically necessary health care services required by plan members.
- Provide prior authorization and assist with denial reviews as well as facilitating short and long term options through interdepartmental communication and referrals for SMI, SEBD, ADRC and case management of members with specialized care or on disease management programs.
- Provide timely computer entry of encounter information and data to maintain an accurate record of clinical reviews and services authorized and provided to Plan members.
- Perform clinical review via phone or on site, and assignment of length of inpatient stay in accordance with all state and federal mandated regulations and AC policy and procedure
- Monitor services provided to members for continuity, medical necessity and appropriateness with recommendation for covered options to prescribers and providers.
- Coordinate discharge planning and assist with appropriate arrangements for outpatient care utilizing high quality, cost effective resources.
- Act as a clinical resource for services conducted by AC non-clinical administrative staff and provide feedback for process and systems improvements.
- Participate in scheduled rounds and interdisciplinary collaboration with professional staff and Medical Director for quality of care issues, medical necessity issues.
- Participate in QI projects, survey process, IRR reviews and orientation of new employees with prior authorization responsibilities.
- Assess turnaround times for PA requests to ensure compliance with Medicaid and Medicare requirements, URAC standards, AC policies and procedures and continuous quality improvement.
- Maintain confidentiality of all Plan and member records and information as specified in the corporate confidentiality policy.
- Assist in the clinical aspects of the day-to-day operations of the Medical Management department as assigned by supervisor or perform other duties as assigned.
- Current valid State of Hawaii Drivers License
- Able to travel within area and occasionally out of area.
Required Licensure / Certification:
- Two years experience in UM
- Recent acute clinical experience within the past two years
- Ability to function independently and coordinate the work of other personnel effectively.
- Exhibit strong planning, organization and time management skills.
- Basic computer knowledge.
- Must possess excellent verbal and written communication skills
Preferred Competencies and Qualifications:
- RN or LPN currently licensed in the State of Hawaii.
- State regulatory experience preferred
- Five years inpatient clinical experience preferred.
- URAC/NCQA and HEDIS exposure an asset.