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Claims Review Nurse

Remote:

Full Remote

Contract:

Full time

Experience:

Mid-level (2-5 years)

Work from:

Canada

Offer summary

Qualifications:

Current RN Licensure in California, Four years experience in Acute Care, Knowledge of McG and Interqual Standards, Strong organizational and time management skills, Professional demeanor with healthcare teams.

Key responsabilities:

Perform medical necessity reviews using McG and Interqual Guidelines
Coordinating discharge planning for complex patients
Ensure communication with physicians about care coordination issues
Conduct focused readmission reviews and identify trends
Prepare reports for UM Committee on compliance and outcomes

Prospect Medical Systems SME https://prospectmedicalsystems.com/

501 - 1000 Employees

See more Prospect Medical Systems offers

Job description

Job Description

The Utilization Review/Management Nurse is accountable for planning, directing, and overseeing aspects of daily Utilization Review operations across ALTA/Southern CA facilities where needed. The Utilization Review/Management Nurse is also responsible in performing and completing medical necessity reviews utilizing McG and Interqual Review Guidelines ensuring adherence to said guidelines for admission and continued stay reviews. The Utilization Review/Management Nurse is also responsible in coordinating the Physician Advisor review/referral process per policy. The Utilization Review/Management Nurse is also responsible in coordinating discharge planning efforts of medically complex patients with barriers to safe transition to the next appropriate level of care. The Utilization Review/Management Nurse is also responsible in performing focused readmission reviews as assigned, identifying trends and recommends action plans based on opportunities and trends identified during the review process.

Responsibilities

Applies medical necessity per hospital approved utilization review criteria to determine appropriate level of care and length of stay
Ensures utilization review is completed and documented concurrently and provided to the patient’s payer as required. Ensures timely escalation of unresolved care coordination issues to the appropriate level. Proactively communicates with physicians to discuss opportunities identified related to lack of medical necessity of admission and continued stay. Recommends level of care, i.e., in-patient or observation based on clinical indicators
Communicates denials and physician related utilization management practices to immediate supervisor timely. Facilitates/coordinates P2P reviews as needed.
Coordinates Physician Advisor referral process. Ensures timely referrals of cases to Physician Advisor and timely Physician Advisor intervention.
Performs focused readmission reviews as assigned, identifies trends and recommends action plans based on opportunities and trends identified during the review process.
Coordinates discharge planning efforts on medically complex patients with barriers to safe transition to the next appropriate of care.
Maintains open lines of communication with Case Managers and Discharge Coordinators to ensure patient’s safe and timely transition to the next appropriate level of care based on identified post-acute services needed.
Assists in preparing reports to UM Committee, including, but not limited to: McG/Interqual compliance-appropriate use of guidelines, timeliness of reviews; Outcomes of Physician Advisor referrals. Works closely with the Denial Management team by providing the Denial Management team with pertinent information relating to patient’s condition that would aid in the appeals process.

Qualifications

Required Qualifications:

Current Licensure as a Registered Nurse in the State of California
Four (4) years of experience in an Acute Care Case Management role or Utilization Management.
Knowledge of McG and Interqual Criteria application
Excellent verbal and written communication skills
Computer literacy and proficiency
Knowledge of all Federal, State and Local regulatory standards
Professional demeanor with healthcare team
Strong Organizational and Time Management skills with ability to effectively prioritize tasks.
Fire and Life Safety Card (Los Angeles City Employees only)

Preferred Qualifications: