Utilization Review Nurse

Description

Absolute Care offers concierge health services using a risk-bearing, PCP-driven care model. We treat the most clinically complex and vulnerable members of the communities we serve, many of whom suffer from behavioral health, substance use, and SDoH challenges.

We use population health management tools to employ a holistic approach to caring for the highest utilizers of healthcare services in our comprehensive care centers and in the community.

Absolute Care tends exclusively to the needs of the top four to six percent of the population who persistently represent a disproportionate amount of unnecessary utilization and cost, regardless of whether they are engaged with other PCPs.

In our more than 20 years of service, Absolute Care has focused on fulfilling the needs of this population. And we have consistently achieved unprecedented outcomes by addressing medical and psychosocial issues, in addition to the hardships of life that can exacerbate chronic health conditions and complicate access to care.

Our Values :

• Accountability - We have the integrity to do what we say we will do
• Caring - The needs of our team and members matter
• Trust - Our members can rely on us
• Teamwork - We act together as one inclusive group

Description :

The Utilization Review Nurse ensures appropriate utilization of health services by performing initial, concurrent and retrospective clinical case reviews.

This role collaborates and communicates with health plans and different providers / care teams to help ensure inpatient bed days and associated discharge / transitional care plans are appropriate.

The Utilization Review Nurse provides clinical review for different healthcare services requiring authorization- including acute inpatient, skilled nursing facility, acute rehab, home nursing as well as others.

Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity and appropriateness of treatment setting by utilizing the applicable policies and guidelines.

Utilizes decision making and critical thinking skills in the review and determination of coverage for medically necessary health care services.

Is part of a team that accountable for facilitating and providing care coordination services and associated quality outcomes for patients across the continuum of discharge planning and transitional care.

Collaborates with different teams to develop and / or implement comprehensive discharge care plans based on assessment of member's clinical and social needs.

• Reviews and interprets medical records and compares against industry guidelines and company policies to determine medical appropriateness and necessity of care.
• Apply critical thinking and decision-making skills to determine if the medical record documentation supports the need for service while maintaining quality standards.
• Continuously reviewing the patients' medical record to ensure that members will not receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.
• As needed, perform onsite of emergent / urgent and continued stay requests for appropriate care and setting, following guidelines and policies.
• Understands key aspects of discharge planning, transitional care management and drivers of readmissions when coordinating care for complex, vulnerable populations.
• Ability to work with multidisciplinary teams and embrace teamwork.
• Identifies members for referral opportunities to integrate with other products, services and / or programs Identifies opportunities to promote quality effectiveness
• Demonstrates proficiency with case load and the ability to manage complex cases effectively
• Works with less structured, more complex issues and ability to identify solutions to non-standard requests and problems.
• Demonstrates a solid understanding of managed care, Medicare, and Medicaid regulations.
• Schedule : Monday thru Friday daytime hours, along with rotating weekends and holidays.

Experience

• Ability to interpret clinical data.
• Active Registered Nurse license by the State of Louisiana and / or the state(s) in which the nurse is required to practice.
• Bachelor's Degree in Nursing from an accredited school of nursing
• Understanding of complex vulnerable populations and their associated care coordination needs.
• Knowledge of medical appropriateness criteria such as InterQual®, Milliman Care Guidelines®
• Experience and knowledge with Medicaid and Medicare managed care organizations, regulations and populations.
• Must have excellent oral, written, and interpersonal communication skills, and must be a creative problem solver.
• Proven ability to meet deadlines and work under pressure.
• Must have good typing skills and proficiency using MS Office Word, Excel and Outlook
• 3-5 years of acute care clinical experience required working in any of the following areas : ER, Critical Care, ICU, Ortho, Med Surg, Telemetry.
• Health plan, ACO or IPA experience.

Our employeesare offered the following benefits

• Free parking
• Free Vision Plan
• Medical and Dental plans
• Life Insurance
• Short Term Disability
• 401 k Retirement plan

AbsoluteCare provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.