About This Role
This nursing role focuses on ensuring appropriate patient care in a hospital network by performing concurrent reviews of clinical information and coordinating discharge planning. The Utilization Review Nurse ensures that care aligns with policy terms and conditions while identifying potential errors or unnecessary treatments.
Responsibilities
- Perform daily concurrent review of patient's clinical information from the hospital network to ensure appropriateness of care in accordance with policy terms and conditions
- Review patients' medical records to identify errors or missed diagnoses that could have been detected earlier in treatment or unnecessary investigation and treatment
- Coordinate patient's discharge planning with UR or UM physician for ongoing cases to ensure appropriate length of stay
- Analyze situations and make decisions based on received information regarding a patient's readiness for discharge from the hospital
- Seek consultation from appropriate disciplines/departments as required to expedite claim decisions and facilitate timely and accurate communication of claim decisions and clinical reviews before discharge
- Refer case issues to team advisor(s) in a timely manner and monitor the issue until it is resolved
- Prepare monthly Utilization Management and cost savings reports in the area of responsibility
- Closely monitor claim TAT to ensure all cases are completed within SLA
- Deliver service with a strong focus on customer satisfaction
- Build strong relationships with hospitals to contribute to a smooth cashless claim journey
- Support peers in the aspect of holistic health claim management
- Ensure the correctness of claim data capturing
- Assist in managing team daily performance
- Develop trusted relationships with involved parties – listen actively to their concerns and questions to better understand their requests and perspectives
- Participate in the overall improvement efforts of the Project Management team by seeking opportunities for feedback and development
- Revisit current processes and define improvements, then identify quick win solutions
- Support internal control tools and internal audit programs for the team to determine appropriate claim authority and performance evaluation aspects
- Help develop work instructions and guidelines for hospitals and claim SOP to increase effective resolution of all claim inquiries
- Establish processes for checks and balances
- Provide stakeholders with feedback related to their performance, such as early claim cases
- Assist in developing SOPs, workflows, and procedures and effectively communicate them to the team
- Timely report significant incidents with immediate action, short-term solutions, and preventive actions
