Utilization Review Nurse - Remote

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Position SummaryThe Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations.

This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes.

The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to ensure members receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.

Job Description Key Outcomes: Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.

Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.

Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources.

This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.

Coordinates referrals to Care Management, as appropriate.

Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g.

Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable.