This role involves performing utilization management and review for a Michigan health plan client, working within their systems and evidence-based clinical criteria. The nurse conducts various reviews to determine medical necessity, appropriate care levels, and length of stay for a wide range of services. It suits a U.S.-licensed clinician with strong clinical judgment and critical thinking skills.
Responsibilities
Review, research, and authorize requests for elective, direct, ancillary, urgent, and emergency services, applying approved clinical criteria to determine medical necessity, level of care, setting, and length of stay
Contact appropriate medical and support personnel to identify and recommend alternatives according to established client protocols
Evaluate clinical documentation against nationally recognized criteria (MCG/InterQual), CMS guidance, and client medical policy; approve/certify when criteria are met and route cases that do not meet criteria to the client's Medical Director for determination
Document all review activity, clinical rationale, and determinations completely and accurately in the client's UM system, in accordance with client policy, regulatory timeframes, and accreditation standards
Support coordination of care by identifying discharge-planning needs, communicating with appropriate internal and external parties, and facilitating referrals/hand-offs to the plan's care management team for members who screen as higher risk
Apply working knowledge of case management practice to recognize members who may benefit from care management, transitions-of-care support, or community resources, build and establish care plans and coordinate care accordingly
Communicate professionally with providers, facilities, members, and client staff to obtain records, clarify requests, and convey approval/certification information; verify identity and consent before disclosing protected health information (PHI)
Identify and document potential quality-of-care or consumer-safety concerns and route them to the appropriate area for resolution
Meet or exceed established productivity, turnaround-time (TAT), and quality/clinical-decision accuracy targets, and participate in inter-rater reliability (IRR) assessments and calibration
Maintain strict confidentiality and comply with HIPAA, fraud-waste-and-abuse controls, the Code of Business Ethics and Conduct, and all applicable client, state, and federal requirements
Complete required onboarding, client certification, continuing education, and license/certification-renewal requirements; assist with precepting and peer documentation review as requested
Requirements
Current active, unrestricted RN license in any state with the ability to obtain the State of Michigan Nursing License (exclusions: Northern Mariana Island, Guam, Puerto Rico)
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Ability to maintain licensure and, where applicable, eligibility for compact/multistate licensure and additional single-state licenses without restriction
Strong team player who possesses strong critical thinking skills, and ability to work independently, while escalating appropriately
Working knowledge of case management practice and coordination of care / discharge planning processes
Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management and utilization review
Capable of working within tight deadlines, detail-oriented and highly organized
Effective communication skills (verbal and written)
Proficient with using technology including ability to multitask across multiple environments including MS Office Applications, PDF, Office
Able to work from home in a distraction free, private office space
Internet to support minimum upload and download speeds
Ability to support up to 10% travel as necessary to include Shearwater Nashville location and client location
Nice to have:
Bachelor of Science in Nursing (BSN) preferred; ADN with relevant experience considered
