Job Description
- Job Description:
- Applies specialized clinical knowledge to perform medical necessity review determinations by applying evidence-based criteria to evaluate the medical necessity and appropriateness of requested healthcare services
- Performs medical necessity reviews 50% of role
- Role is responsible for ensuring that the products, services, and operations of the Medical Review department meet established quality standards
- Collaborates with leadership and quality team members to complete quality assurance audits for stateside and offshore vendor team Medical Review Nurses in an effort to help team maintain and improve team quality standards
- Performs quality audits 50% of role
- Assists leadership with coaching and guidance to all nursing staff, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making
- May require daily communication with external vendor partners
- Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members
- Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources
- Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies
- Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization
- Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function
- Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes
- Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance
- Requirements:
- Active unrestricted state Registered Nurse licensure in state of residence required
- Minimum 5 years of relevant experience in Nursing
- 2-3 years of varied Utilization Management (UM), Medical Review (MR), or Case Management (CM) experience
- 5 years clinical experience required in a variety of settings including acute care, home health, or long-term care
- 5 years demonstrated ability to make thorough, independent decisions using clinical judgement
- Remote/work at home experience
- Prior Relevant Work Experience specific to Medical Necessity Review for 3-5 years
- Benefits:
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
Apply tot his job
Apply To this Job