Description

Under the direction of the Medical Management Director, the Utilization Management (UM) Nurse is responsible for analyzing clinical information submitted by medical providers to evaluate the medical necessity, appropriateness and efficiency of the use of medical services, procedures and facilities. The UM Nurse is also expected to maintain valid, unencumbered licensure in any region that the health plan operates. The UM Nurse is responsible for clinical review of all requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse is also responsible for making phone calls to providers 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 telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director. The UM Nurse is responsible for telephonic availability during non-business hours to assist with medical necessity reviews for medical services, procedures or facility usage. The UM Nurse promotes quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse will also utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.

MAJOR RESPONSIBILITIES

• Proactively analyze information submitted by providers to make timely medical necessity review determinations based upon evidence based clinical criteria and standards within governmental and contractual 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
• Collects accurate data for system input by using correct coding of diagnoses and/or procedures
• Processes authorization requests via phone queue according to internal departmental processes.
• Performs selected provider calls 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 telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director.
• Maintain documentation of all contacts with providers for health management activities to meet all regulatory and contractual requirements.
• Be available for after-hours telephonic utilization review needs of providers as mandated by governmental and contractual guidelines
• Establishes and maintain rapport with providers as well as ongoing education of providers concerning appropriate protocol.
• Appropriately refers member for case management services who have complex case management, transition of care, disease management or other identifiable needs for coordination of the member's health care.
• Refers member who have high dollar utilization needs to dedicated health plan staff and reinsurance provider.
• Support cost effective care by assuring in-network resources are being used in a timely manner whenever possible. Collaborate with provider relations for out of network contracting as needed.
• Collaborates with and maintains open communication with all other departments as appropriate and required to facilitate completion of all tasks and goals
• Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
• Protects confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Adhere to URAC and NCQA Standards
• Maintain valid, unencumbered licensure in all states, regions or territories that the health plan operates.
• Maintains all professional CEU's in compliance with State and Regulatory requirements.
• Utilize critical thinking skills, clinical judgement and the nursing process to evaluate the need for requested clinical services, processes or facility use.
• Communication, Collaboration and Coordination with all customers, internal and external
• Maintain clinical competencies by attendance at selected nursing meetings and/or documentation of educational activities.
• Attend bi-weekly departmental staff meetings.
• Ability to sit for long periods of time.
• Ability to organize and prioritize work to meet contractual deadlines.
• Ability to work occasional long or irregular hours to meet business needs.
• Good speaking ability, judgement and initiative.
• Ability to work a flexible work schedule including evening and weekends.
• Demonstrate organizational, time management, prioritization and team-work skills.
• Work autonomously and be directly accountable for results.
• Function effectively in a fluid, dynamic, and changing environment.

Education/Skills

• Nursing School Diploma, Associate or Bachelor's Degree in Nursing required; Bachelor's Degree preferred
• Valid unencumbered Texas RN licenseExcellent communication skills, (written and verbal) judgment, initiative, critical thinking and problem-solving abilities
• Competent in Microsoft software (e.g. Word and Excel)
• General computer knowledge and capability to use computers required.
• Proficient typing skills.
• Excellent telephonic customer service skills.
• Superior clinical judgement

Experience

• Minimum of 3-5 years experience of direct patient clinical care
• Minimum of 1-3 years experience in a managed care environment or health plan preferred
• Ability to work in a variety of settings with culturally-diverse communities with the ability to be culturally sensitive and appropriate
• Knowledge of managed care principles, HMO and Risk Contracting arrangements.

Licenses, Registrations, or Certifications

• Licensed registered nurse (current and unrestricted) in the State of Texas
• Obtain RN licensure within 3 months of hire in any other State that health plan operates and licensure is required
• Certification in Case Management preferred or must be achieved within two years of hire.