Concurrent Nurse Reviewer - Facility Utilization Review Unit

1. Applies appropriate medical necessity criteria from established medical
policies and clinical practice guidelines to apply concurrent review
determinations as described in the Medical Management UM work plan.
* This detailed clinical judgment includes determination of inpatient
hospital stays as medically appropriate for the member's clinical
condition or whether the stay requires referral to a Medical Director for
potential denial.
* The Nurse Reviewer must follow each line of business requirements and each
accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient
admission.
* Responsibilities include using 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 and appropriate
* Promote decreased lengths of hospital stays when appropriate
* Ensure the quality-of-care member is receiving during hospital stay is
appropriate
* Ensure appropriate levels of care are received by patients
* Consult with Medical Directors on potential quality issues encountered
during review of medical records in situations when the complexity of
the member's medical, surgical and/or pharmaceutical management is
unclear and may require further review or intervention and follow up
with attending physicians, hospitalists, or other facility staff
2. Provide appropriate consultation and referral to Case Management or QUEST
Integration program as appropriate
3. Identify appropriate alternative and non-traditional resources and
demonstrate creativity in managing each case to fully utilize all available
inpatient and community resources.
4. Identifies cost savings and accurately records all communications and
interventions.
5. Evaluates suspended claims against medical records to determine the medical
necessity and appropriateness of medical services, identify irregularities
such as over or under-utilization of services, potential up-coding, over
billing, etc.
6. Communicates timely, accurate information either verbally or in writing
using clinical judgment, knowledge of medical/reimbursement policies and
plan benefits to internal MM staff, other internal departments (Claims
Administration, Customer Relations, etc.), providers, members, and other
authorized persons.
* For denied services, ensures the denial, benefit and appeal language are
accurate and consistent with department procedures, accreditation, and
regulatory guidelines.
7. Identifies and refers members with specific medical and/or behavioral health
needs or complex case management and collaborates with case management staff
as needed. Also identifies and refers quality of care issues and suspected
fraud, waste, or abuse to the appropriate departments.
8. Performs all other miscellaneous responsibilities and duties as assigned or
directed.

#LI-Hybrid

Qualifications

1. Associates Degree in Nursing
2. Two years clinical care experience or case management; or related
experience.
3. Knowledge of the appropriate protocol to be followed for a given diagnosis
and the normative values of medical tests and procedures.
4. Good typing skills: Typing speed of 40 wpm
5. Strong organizational skills
6. Good communication skills: verbal and written
7. Basic working knowledge of Microsoft Office applications. Including but not
limited to Word, Excel, and Outlook.
8. Currently licensed in Hawaii as an RN or LPN
* (if applicable upon hire, proof of licensure to be provided by employee or
confirmed by Human Resources)