About This Role
This nursing role focuses on performing utilization reviews for Workers' Compensation cases, including prospective, concurrent, expedited, and retrospective reviews to determine the medical necessity and appropriateness of requested care. It involves using evidence-based criteria and identifying patients with ongoing case management needs for referral to the Case Management team.
Responsibilities
- Conduct first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests
- Review all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
- Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate
- Conduct reviews within state jurisdiction and URAC timeframes
- Review length of stay for inpatient cases when applicable
- Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating services
- Identify and review with Medical Director any case with potential safety issues
- Promote cost-effective health care with an aligned health provider network
- Identify and refer to Telephonic Case Management / Pharmacy TCM
- Coordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals
- Manage determinations within the pharmacy portal
- Perform NY PAR in the onboard system in accordance with NY MTG Guidelines
- Demonstrate ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards
- Maintain established template documentation standards adhering to URAC standards and company policies and procedures
- Maintain minimum billing and report billing hours in accordance with case activity and billing practices
- Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHI
- Perform other job duties as assigned
Requirements
- Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred
- Current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required
- Ability to obtain additional licensure based on jurisdictional assignment
Nice to have:
- Interstate nurse compact licensure
- CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification
