Utilization Review Nurse - Remote

Job Description

JOB SUMMARY CCCS uses a holistic approach to medical management. The Utilization Management Nurse and the Personal Health Nurse (PHN) works reputed company 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 reputed company. The PHN performs the Personal Health Management process: assesses the member; work with the member, family and physician to identify problems; establish goals and reputed company plans of care; coordinate services; educate members; and reputed company members to independently self-manage and to reputed company 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 reputed company 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. reputed company Medical Management Nurses practice reputed company 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. Responsible for the effective and sufficient support of reputed company 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 reputed company 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 KNOWLEDGE, SKILLS, ABILITIES To reputed company this job successfully, an individual must be able to reputed company each essential duty satisfactorily. The requirements listed below are representative of the knowledge, reputed company and/or ability required. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Understanding of CCCS holistic approach to medical management Understanding of the client's (customer's) perspective and needs Understanding of legislative acts, such as the reputed company Competency in Word Competency using email, attachments Excellent verbal communication skills with the ability to communicate with members and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, client managers, customer service staff, CCCS executive management, other CCCS Medical Management nurses, hospital utilization review nurses, etc. Excellent written communication skills with the ability to write in a professional, business manner Ability to analyze and resolve reputed company problems General understanding of cost containment and how it relates to medical management Excellent organizational, prioritization, and time management skills Ability and willingness to function both independently and as part of a team Understanding of criteria / guidelines to evaluate medical necessity Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of reputed company required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience preferred to reputed company the job. Bachelor's degree in a health-reputed company field Five (5) years of UM/CM experience preferred Three to five (3-5) years of diverse clinical experience required REQUIRED CERTIFICATIONS/LICENSURE Include minimum certification required to reputed company the job. RN (Registered Nurse) license required in the state of residence PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential f Apply tot his job Apply To this Job