Utilization Review Nurse

Description JOB SUMMARY CCCS uses a holistic approach to medical management. The Utilization Management Nurse and the Personal Health Nurse (PHN) works within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means. The UMN provides utilization review/pre-certification on various members under designated group contracts. The PHN performs the Personal Health Management process: assesses the member; work with the member, family and physician to identify problems; establish goals and develop plans of care; coordinate services; educate members; and empower members to independently self-manage and to make knowledgeable health care decisions. Both the UMN and PHN work closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s). Additionally, the UMN may interface with clients and CCCS client managers and are responsible for the medical management of designated client(s) in conjunction with PHN’s, client specific and external case managers. All Medical Management Nurses practice within the scope of their licensures. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Collecting, analyzing, and evaluating clinical documentation received to determine appropriateness of clinical decisions Adherence to regulatory and departmental timeframes for review of requests received 3. Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies. Using an established set of criteria evaluates, applies and authorizes the medical necessity of inpatient and outpatient services. Referring to medical director when unable to approve a request. Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and channeling to network providers. Uses clinical knowledge and evidence based criteria to determine the medical necessity of an inpatient admission, treatment plan and goals, identified gaps, risk for readmission or complications and any barriers to discharge Collaborates with case / disease management departments and vendors to support client contractual agreements, SLA’s, SPD’s to ensure member receives quality care Supports quality assurance initiatives, quality indicators and performance standards following standard documentation and ERISA / URAC guidelines SUPERVISORY RESPONSIBILITIES If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. KNOWLEDGE, SKILLS, ABILITIES To perform this job succes