Position purpose: Utilizing approved criteria, member eligibility, and benefit coverage and/or policies, performs initial utilization reviews, including pre-admission certifications, prior authorizations, continued stay review, concurrent reviews, discharge review and retrospective reviews to verify appropriate member use of benefits at the medically necessary level of care for the member’s severity of illness and intensity of care needs. The reviews may include but are not limited to:
- In-patient Out-patient
- Procedure Level of Care
- Off-plan Out-of-Network
- Behavioral Health, Transplant Coordination
- Case Management, Durable Medical Equipment
- Medication, Home Care
- Specialty Reviews, Discharge and Discharge Planning
To perform this job successfully, the individual must be able to perform each essential duty satisfactorily (the requirements listed below are representative of the knowledge, skill and/or ability needed). Reliable, consistent and predictable performance of the following job duties is required:
NOTE: Utilization Review Nurses do not issue clinical denials. They perform initial reviews using approved clinical criteria and/or policy. When cases do not meet the clinical criteria/policy, they are referred to the Plan Medical Director or his/her physician designee for review with all supportive documentation. Only the Medical Director or his/her physician designee may issue a clinical denial.
- Performs utilization review and coordination of care functions. Reviews conducted are based on approved criteria, eligibility, and benefit coverage and/or clinical policy for all levels of care, equipment and services to determine appropriateness and, when applicable, length of stay. Identifies the most cost-effective setting, while providing quality alternatives.
- Reviews selective outpatient services against approved medical criteria, member eligibility, and benefit coverage and/or policy.
- Collaborates with requesting provider to collect pertinent medical, psychological and social assessments to assist in decision and alternative care options for chronic and catastrophic cases.
- Documents the case review decisions in PHP’s information system including referrals to the Medical Director, reason for recommended denial, appropriate notifications and any other information relevant to the case.
- Participates actively in staff meetings, being prepared to discuss cases and collaborate with the multidisciplinary team on case decisions.
- When needed, completes reviews for off-plan and out-of-network utilization and coordination of care activities.
- Reviews relevant member medical diagnostic and treatment information compared to eligibility and benefit coverage. Accurately enters updated member’s diagnostic and treatment information, generating individual electronic or paper documents for each treatment/service request within established timeframes.
- Inputs patient admission and discharge information per PHP’s system, taking telephonic and electronic record reviews and assessments as needed. Documents pertinent information sufficient to justify decision-making pertaining to the case, as well as determining the status and needs of patient.
- Refers issues or opportunities that cannot be addressed by the member’s benefit plan to the Director of Medical Management for discussion with the management team to determine if “extra contractual” arrangements can/should be made to assist in a more cost-effective and quality alternative for the identified needs.
- Documents and meets all reviews and notifications within the time requirements as set by federal or state code and/or PHP policy.
- Collects and maintains accurate statistical and tracking data as required or requested by Senior Team, the Director of Medical Management and/or department/PHP policy and process guidelines.
- Monitors the Plan-of-Care on an ongoing basis to ensure the plan has achieved a positive outcome for the member, provider, and the Plan.
- Assists in identifying community resources that will provide the member with additional support or assistance, which may not be available from the Plan’s network of health care providers.
- Actively participates in the Quality Improvement/Utilization Review Program as well as company-wide and departmental quality management activities. Provides assistance in the maintenance of statistics and activity documentation related to the program. Complies with the implementation of Action Plans and process changes as a result of program activities. Reports variations or ideas for improvement to contribute to the continuous improvement of services to members and processes of PHP.
- May be assigned as department representative on committees or action groups.
- Informs the Director of Medical Management of problematic cases, and brings forth issues that the manager needs to be aware of, serving as a constructive participant in developing responses to problems and issues.
Utilization Review Nurses are not given financial incentives for decisions that result in underutilization, adverse determinations, or denials.
- Maintaining the highest levels of confidentiality.
- Maintaining effective relationships with employees and external contacts.
- Must be able to work with a wide variety of people to solve problems.
- Strong diplomatic skills.
- Extensive use of computer systems.
- Managing multiple projects and priorities simultaneously.
- Maintaining accurate records and tracking devices.
- Selecting and monitoring the best “plan-of-treatment” to ensure a positive outcome for the client, provider and PHP.
- Strong organizational skills.