Utilization Review Nurse

Job Description:

· Participates in the development and ongoing implementation of QM Work Plan activities.

· Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives

Responsibilities:

· Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.

· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

· Data gathering requires navigation through multiple system applications.

· Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.

· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.

· Responsible for the review and evaluation of clinical information and documentation.

· Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.

· Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).

· Independently coordinates the clinical resolution with internal/external clinician support as required.

· Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data

· Prepares and completes QM documents based on interpretation and application of business requirements

· Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements

· Assists in the development and implementation of QM projects and activities

· Accountable for completing and implementation of QM Work Plan Activities

Experience:

· 3+ years of experience as an RN

· 1+ years of inpatient hospital experience

· Registered Nurse in state of residence

· Must have prior authorization utilization experience

· Able to work in multiple IT platforms/systems

Skills:

· MUST HAVE MEDCOMPASS or ASSURECARE exp.

· MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.

· MUST HAVE UM experience, inpatient utilization management review.

· MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.

· MUST HAVE 6 months of Prior Authorization.

Education:

· Active and unrestricted RN licensure in state of residence