- Coordinates and reviews all medical records, as assigned to caseload
- Actively participates in Case Management and Treatment Team meetings
- Serves as on-going educator to all departments
- Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
- Able to work independently and use sound judgment.
- Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
- Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
- Responsible for providing timely and accurate referral determination
- Identification of referrals to the medical director for review
- Appropriate letter language and coding (denials, deferrals, modifications)
- Appropriate selection of the preferred and contracted providers
- Proper identification of eligibility and health plan benefits
- Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
- Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
- Meets or exceeds production and quality metrics.
- Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
- Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
- Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
- Performs other duties as assigned.
- CA LVN license required. CA RN license preferred.
- Bachelor's or Master's degree in Social Work, behavioral or mental health, nursing or other related health field preferred
- 3 to 5 years of acute care experience preferred.
- Two (2) years managed care experience in UM/CM Department, preferred
- Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
- ICD-9 and CPT coding experience a plus
- Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
- Experience in EZ-CAP preferred
- Medical Terminology preferred
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Utilization Review Nurse - Corona, United States - KPC Global MSO
Description
Victor Valley Global Medical Center
Victorville, CA
