The Utilization Management Nurse is responsible for conducting utilization and quality management activities in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities. This is a full time position
Nature & Scope
* Strong communication, documentation, clinical and critical thinking skills is essential.
* Working knowledge of utilization management/case management preferred.
* Strong problem solving and decision making skills essential.
* Strong typing and computer skills essential.
Minimum Job Requirements
Education: Licensed Practical Nurse with an unrestricted license
Experience: Experience in med/surg (hospital nursing preferred).
Utilization review experience preferred.
Experience in utilization review, quality assurance, discharge planning or other cost management programs preferred.
Directly related experience using Milliman criteria or healthcare criteria preferred.
Behaviorial health experience in multiple levels of care for Behaviorial Health Utilization Management preferred.
Call center knowledge desirable.
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
• Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities;
• Must become knowledgeable of URAC requirements for clinical staff for UM accreditation;
• Performs telephonic review for inpatient and outpatient services using Milliman criteria.
• Collects only pertinent clinical information and documents all UM review information using the appropriate software system;
• Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with health plan clients’
• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
• Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
• Makes referrals to Care Manager for coordination and collaboration with providers regarding alternative care options and education.
• Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement;
• Participates in UM program CQI activities;
• Communicates all UM review outcomes in accordance with the health plan client profile procedures.
• Follows relevant client time frame standards for conducting and communicating UM review determination;
• Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures.
• Identifies and communicates to the Director of Utilization Management, all hospital, ancillary provider, physician provider and physician office concerns and issues;
• Identifies and communicates to the Director of Utilization Management, QPM, supervisor all potential quality of care concerns and patient safety;
• Serves as liaison for provider staff and the health plan client;
• Maintains courteous, professional attitude when working with Health Integrated HealthCare staff, hospital and physician providers, and health plan client;
• Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high risk cases for case management referral;
• Active participation in team meetings; and
• Performs other duties as requested by the Director of Utilization Management.
• Supports a positive working environment;
• Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Director of Utilization Management, QPM, as a resource;
• Communicates to Director of Utilization Management all problems, issues and/or concerns as they arise;
• Communicates to the Director of Utilization Management and QPM any issues or concerns related to qualify of care.
• Maintains a courteous and professional attitude when working with all BANA BT WM staff members and the management team;
• Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role;
• Actively participates in team meetings, as designated.
Arkansas Blue Cross and Blue Shield - 9 months ago