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
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