The purpose of this position is to ensure that Archcare Advantage members obtain timely, cost-effective, quality care in the appropriate setting. The primary role of the Utilization Review (UR) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that our members receive all appropriate medical services in compliance with medical and regulatory guidelines. Responsibilities include, but are not limited to, review and authorization of Outpatient Services. review of requests for pre-authorization of elective admission and procedures. inpatient admission review. review of continuing stay and discharge planning. and coordination of care and services of select member populations with common chronic conditions. In all areas, the UR Nurse is charged with managing the delivery of care in an effective, professional and compassionate manner.
Responsibilities? Under the direction of the Director of Clinical Operations and in coordination with the Medical Directors, the UR Nurse is responsible to apply the Nursing Process to review and evaluate all clinical services provided to our members. The UR Nurse will help our providers give quality, evidence based care in an effort to reduce costly complications, optimize therapeutic outcomes, and improve the quality of life of our members. The Utilization Review Nurse at any time may have to assume the responsibilities of covering the Inpatient Services, Outpatient Services or the Disease Manager role. Responsibilities include, but are not limited to the following:? Tasks specific to Inpatient Concurrent Review assignment: Review and evaluate all requests for elective inpatient admission. Authorizes those inpatient requests that meet the health plan's approved UM criteria and policies in the Clinical Services P&P Manual. Identify on a daily basis all Archcare Advantage members who are currently hospitalized. Conduct initial inpatient review and determine the appropriateness of admission, anticipated length of stay and potential discharge needs. Prioritize the review of patients according to the relevant Clinical Services Policy and Procedures. Accept telephonic and faxed reviews. Document the inpatient review in the computer system including diagnosis, procedures, attending physician, treatment plan, anticipated length of stay, and the Interqual Criteria used to justify continued stay. Perform concurrent review and enter information in the computer system in a timely manner. Assess and coordinate referrals for inter-hospital transfers and specialty care. Appropriately and expeditiously refer cases to the Medical Director, process Medical Director's decision in the computer system. Generate Approval and Denial letters based on Medical Director's determination. Expeditiously alert providers by phone of denials. Appropriately refer cases to re-insurer in a timely manner. Actively participate in Clinical Rounds. Actively participate in the discharge planning process with the facility discharge planner to ensure timely discharge, appropriate follow up and continuity of care. Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation. Refer cases with quality of care concerns to the Medical Director and Quality Improvement Dept. Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer.? Tasks specific to Outpatient Services assignment (Specialist Authorization and Pre-certification of Ambulatory procedures): Review and evaluate all requests for office visits, home care, outpatient procedures, ambulatory surgery and transportation according to Archcare Advantage's UM guidelines and the standards specified in the Archcare Advantage Utilization Manual. Accept telephonic and faxed reviews. Authorizes those requests that meet the health plan's approved UM criteria and the policies in the Clinical Services P&P Manual. Appropriately document the review in the computer system including: diagnoses, procedures, specialists, treatment plan, and the Interqual Riteria used to justify the approval of request. Appropriately and expeditiously, refer cases to the Medical Director; process Medical Director's decision in the computer system. Generate Approval and Denial letters based on Medical Director's determination. Expeditiously alert provider of phone denials. Refer cases with quality concerns to the Medical Director and Quality Improvement Dept. Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer. Assist members in accessing services, including making appointments for members when appropriate and providing patient teaching and support to facility compliance with treatment.? Other Duties and Responsibilities for all UR Nurses: ? Must comply with all ArchCare Advantage policies and procedures ? Perform follow-up phone calls to facilitate obtaining of documents for any member visit or admission to Facilities, ER, Hospital ? Maintain confidentiality of all member information in compliance with HIPAA requirements ? Accept and perform o Additional duties as assigned within the scope of Nursing knowledge and skills and o Other duties in support of the goal of timely and efficient care deliveryQualificationsExperience Requirements? o At least five years experience as a nurse in an adult acute care setting (ER, Critical Care, Med/Surg) o Experience in Managed Care organizational environment is preferred o If not currently working in Managed Care, requires at least three years of their nursing career must have been in an adult acute care setting (ER,Critical Care, Med/Surg_ o Experience in Home Health, Community Health/Outreach and Discharge Planning is a plusLicense Requirements? o Current licensure as a Registered Nurse or licensure as a Practical Nurse in New York StateSkill Requirements? Required Knowledge and Skills: o Must have the ability to communicate effectively in English. The ability to communicate in a second language is preferred o Must be self-motivated and possess the ability to solve problems independently o Must be committed to being a patient advocate o Must have the ability to work with other professional and para-professional staff in a collaborative manner. Must be a team player o Must display a commitment to quality in practice and documentation o Must be able to follow through on all projects in a timely manner. o Must possess basic-computer knowledge and show a willingness to learn more advanced skills o Must demonstrate an awareness of the legal issues in patient care and strive to manage situations in a manner that reduces risk
Associated topics: ccu, intensive, intensive care, maternal, nurse, nurse rn, psychatric, psychiatric, recovery, transitional