About This Role
This nursing role focuses on reviewing requests for medical services against national clinical guidelines to ensure high-quality, cost-efficient medical outcomes for enrollees. The Utilization Management Nurse applies professional judgment in selecting appropriate guidelines and policies, and screens enrollees for various initiatives and programs.
Responsibilities
- Review precertification requests for medical necessity, referring complex cases to the Medical Director
- Review clinical information for concurrent reviews, extending inpatient lengths of stay as appropriate
- Establish effective rapport with employees, professional support staff, customers, clients, patients, families, and physicians
- Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to promote improved quality of care and/or life, promote cost-effective medical outcomes, prevent hospitalization when possible, promote decreased lengths of hospital stays when appropriate, prevent complications in patients, provide for continuity of care, and assure appropriate levels of care are received
- Provide appropriate referrals to Case Management
- Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources
- Maintain accurate records of all interventions
- Perform utilization review for all members requiring services that need authorization
- Conduct assessment of medical necessity utilizing MCG online criteria
- Gather all pertinent information from providers and facilities to ensure GCHP physician reviewers have sufficient information to make a decision to approve or deny services
- Coordinate with non-clinical staff to ensure all documentation is completed timely and professionally
- Interface with internal resources, including Medical Directors and other Health Services staff, to ensure members receive the right care at the right time in the right setting by the right provider
Requirements
- Ability to work under stress, both with and without supervision
- Attention to detail and a tolerance for handling a heavy workload
- Professional nursing theory, principles, and practices
- Principles and practices of utilization management
- Ability to effectively apply acute care medical/surgical nursing practices
- Ability to use clinical guidelines for medical necessity determinations
- Demonstrated ability to problem-solve complex, multifaceted, emotionally charged situations
- Ability to successfully manage conflict, negotiating "win-win" solutions
- Strong organizational, task prioritization and delegation skills
