Utilization Review Nurse

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Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team.

Minimum Qualifications

Education, Certification, and/or Licensure

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

Experience

1. Three (3) years of healthcare clinical experience.

Preferred Qualifications

Education, Certification, and/or Licensure

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

Experience

1. Medical Management for Medicare and/or Medicaid populations.

2. Utilization Management experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.

2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.

3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.

4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.

5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.

6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.

7. Understands the data that is collected within the position, and work with other team members on improving outcomes.

8. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

Skills and Abilities

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

Attention to detail.

5. Proficiency with Microsoft Office.

Additional Job Description

This role may require occasional weekend and holiday work.

Scheduled Weekly Hours

40

Shift: Exempt/Non-Exempt:

United States of America (Exempt)

Company

PHH Peak Health Holdings

Cost Center

2403 PHH Medical Management