Job Summary:
Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with regulatory benchmarks, ensuring precision and compliance in medical record reviews. This role will include Utilization Review/Management (UR/UM) across a variety of service areas, such as Durable Medical Equipment (DME), acute care, inpatient admissions, third-party outpatient (TPO) services, imaging, genetic testing, and other medical services.
Responsibilities:
- Assures accuracy and timeliness of all applicable review-type cases within contract requirements.
- Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
- In collaboration with the Supervisor, responsible for quality monitoring activities.
- Maintains current knowledge base related to review processes and clinical practices related to the review processes; functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
- Functions as providers’ liaison for customer service issues and problem resolution.
- Performs all applicable review types (including DME, acute, inpatient, outpatient, imaging, genetic testing, etc.) as workload indicates.
- Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
- Attends training and scheduled meetings for current/updated information.
- Cross-trains and performs duties to provide a flexible workforce to meet client/customer needs.
- Reads, understands, and adheres to all corporate policies, including policies related to HIPAA and its Privacy and Security Rules.
Required Qualifications/Experience:
- Active, unrestricted RN license in the state of Colorado or a Compact state license, per contract requirements.
- A minimum of a diploma, certificate, or degree in Nursing.
- 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
- 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.
- Experience reviewing medical necessity for services including DME, acute care, inpatient, TPO, imaging, genetic testing, and other related categories.
- 1+ years of knowledge of InterQual criteria, Milliman Care Guidelines (MCG), and/or other state/nationally recognized criteria.
- Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
- Strong clinical assessment and critical thinking skills.
- Excellent written and verbal communication skills.
- Flexibility and strong organizational skills.
Preferred Qualifications/Experience:
- An Associate, Diploma, or Bachelor’s degree from an accredited college or university in Nursing or a related field.
- Knowledge of current National Committee for Quality Assurance (NCQA) standards.
- Knowledge of Utilization Review Accreditation Commission (URAC) standards.
- Ability to work in a team environment.
- Proficient in Microsoft Office.
- Efficient time management, including the ability to prioritize tasks and meet deadlines.
- Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.