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utilization review nurse - , RI, United States - US Tech Solutions, Inc.
Description
Job Description:
· Participates in the development and ongoing implementation of QM Work Plan activities.
· Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
· Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
· Data gathering requires navigation through multiple system applications.
· Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
· Responsible for the review and evaluation of clinical information and documentation.
· Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
· Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
· Independently coordinates the clinical resolution with internal/external clinician support as required.
· Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
· Prepares and completes QM documents based on interpretation and application of business requirements
· Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
· Assists in the development and implementation of QM projects and activities
· Accountable for completing and implementation of QM Work Plan Activities
Experience:
· 3+ years of experience as an RN
· 1+ years of inpatient hospital experience
· Registered Nurse in state of residence
· Must have prior authorization utilization experience
· Able to work in multiple IT platforms/systems
Skills:
· MUST HAVE MEDCOMPASS or ASSURECARE exp.
· MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
· MUST HAVE UM experience, inpatient utilization management review.
· MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
· MUST HAVE 6 months of Prior Authorization.
Education:
· Active and unrestricted RN licensure in state of residence
