Clinical Care Reviewer UM - RN position at Keystone Mercy Health Plan in Indianapolis

Keystone Mercy Health Plan is presently looking of Clinical Care Reviewer UM - RN on Fri, 03 May 2013 02:50:42 GMT. Position Summary: Under the supervision of the Supervisor, Utilization Management, the Clinical Care Reviewer Nurse is responsible for completing medical necessity reviews using KMHP policies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge...

Clinical Care Reviewer UM - RN

Location: Indianapolis Indiana

Description: Keystone Mercy Health Plan is presently looking of Clinical Care Reviewer UM - RN right now, this position will be placed in Indiana. Detailed specification about this position opportunity please give attention to these descriptions. Position Summary:
Under the supervision of the Supervisor, Utilization Management, the Clinical Care Reviewer Nurse is responsible for complet! ing medical necessity reviews using KMHP policies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge planning requests Consistently applies medical health benefit policy and medical management guidelines to authorize services. Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met.

Principal Accountabilities:
Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the de! termination).

Verifies and documents member eligibili! ty for services.

Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).

Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

Applies submitted information to KMHP authorization process (utilizing Milliman, USA, Interqual medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.

Coordinates with the referral source if insufficient information is not available to complete the authorization p! rocess. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows KMHP process for requesting additional information.

Refers cases to KMHP Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.

Documents case activities for Utilization determinations and discharge planning in MeDecision in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.

Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner.

Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)

Submits appropriate documentation/clinical information to clerical support for! record keeping and documentation requirements.

Recognizes opp! ortunities for referrals to Care Coordination Department, and refers accordingly.

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Maintains awareness and complies with KMHP authorization timeliness standards based on DPW/NCQ requirements.

Performs other related duties and projects as assigned.

Adheres to KMHP policies and procedures.

Supports and carries out the Mercy Mission & Values.

Obtains necessary professional education required for licensure and any applicable certifications.

Complies with KMHP and HIPAA confidentiality requirements and ensures protection of member personal identifiable health information.

Obtains continuing education required to maintain licensure.

Perform on-site review and off-site activities as business needs are identified.

Position Qualifications/Req! uirements:
Education and Training:
Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor’s Degree program

Experience:
Minimum of 3 years of nursing experience in acute clinical setting

Minimum of 2 years case management experience

Excellent knowledge of Milliman criteria

Experience in utilization review and discharge planning

Licenses, Registrations or Certifications:
Current Indiana Registered Nurse License required

Valid drivers license and reliable automobile transportation for on-site assignments and off site work related activities
- .
If you were eligible to this position, please email us your resume, with salary requirements and a resume to Keystone Mercy Health Plan.

If you interested on this position just click on the Apply button, you will be redirected to the official website

This position starts available on: Fri, 03 May 2013 02:50:42 GMT

Apply Clinical Care Reviewer UM - RN Here