Job Description

Utilization Review Nurse Health Plans-HP Utilization Mgmt at Christus Health summary:

The Utilization Review Nurse evaluates the clinical appropriateness and necessity of medical services for patients, ensuring proper resource use and compliance with healthcare guidelines. This role involves pre-admission, concurrent, and retrospective reviews, communication with clinical professionals and insurance providers, and adherence to regulatory and privacy standards. The nurse must apply critical thinking, clinical judgment, and effective communication in a fast-paced environment to promote cost-effective, quality healthcare outcomes.

Summary:

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
• Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
• Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate.
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:

Education/Skills

• Graduate of an accredited school of vocational nursing or equivalent required
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred

Experience

• 3 – 5 years of nursing experience preferred
• Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
• General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

• LVN license in the state of employment or compact required
• RN license in state of employment or compact preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

Keywords:

Utilization Review Nurse, medical necessity review, clinical appropriateness, prior authorization, healthcare compliance, insurance coordination, patient care evaluation, nursing critical thinking, healthcare utilization management, medical service authorization

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