Post Review Nurse Health Services

Use Your Strengths as a Post Review Nurse! 

About the opportunity: As a Post Review Nurse you will utilize clinical knowledge and expertise to interpret and appropriately apply medical policy InterQual criteria and benefit information to postservice claims in a productionbased environment with timeframe and quality metrics. In addition you will provide consultation to utilization management requests and claims inquiries. As part of a multidisciplinary team you will collaborate with internal teams to continuously look for ways to improve processes and maximize health dollars for our members.  

About you: You are passionate about making healthcare better and enjoy a role where you can be both collaborative but also work independently to make an impact. You thrive in a fastpaced work environment where your time management prioritization and multitasking skills are critical to success. You see yourself as being resourceful and adaptable. Technology savviness such as experience in utilizing and troubleshooting Microsoft Office products (Outlook Excel Teams etc) is a must.   

*Candidates located in Iowa or South Dakota preferred. This role is remote eligible and will require candidates to provide highspeed internet at their work location. 

Qualifications :

Required Qualifications Must have:

• Completion of an Accredited Registered Nursing Program or Licensed Practical Nursing Program.
• Active and unrestricted RN or LPN license in Iowa or South Dakota; individual must be licensed in the state in which they reside.
• 4 years of experience including:
• 4 years of clinical experience in an acute care or outpatient setting with a minimum of 4 years of fulltime equivalent of direct clinical care to the consumer.
• Knowledge of the diagnosis and procedure coding systems i.e. ICD9CM HCPC CPT.
• Problem solving and analytical skills; ability to research complex issues obtain relevant information identify inconsistencies etc.
• Strong written and verbal communication skills with the ability to clearly and concisely communicate information to stakeholders.
• Attention to detail and demonstrated skill in making accurate assessments of patient conditions through medical record review.
• Time management and prioritization skills.
• Proficiency with computer Software applications e.g. electronic charting Microsoft suite documentation systems etc.
• Demonstrated knowledgeable of regulatory standards and regulations e.g. URAC NCQA HIPAA PHI confidentiality.
• Resourceful selfstarter who demonstrates strong understanding of resources processes and guidelines. Able to make independent decisions or recommendations under ambiguity.
• Ability to organize and manage multiple priorities in a dynamic work environment where quality and/or production goals are measured. Commitment to timeliness follow up accuracy and attention to detail. Flexible and adapts to change.
• Develops collaborative relationships with peers team members and stakeholders; viewed as a trusted partner.
• Maintains courtesy and professionalism when engaging with members and providers internal and external stakeholders.
• Strong technical acumen; learns new systems quickly e.g. Microsoft Office clinical documentation platforms etc.

Preferred Qualifications Great to have:

• Active and unrestricted RN license in Iowa or South Dakota.

Additional Information :

What you will do as a Post Review Nurse:

*Must be flexible and have the ability to take evening or weekend calls for members who need this arrangement.*

a. Provide timely processing of utilization management reviews claims and inquiries by utilizing clinical knowledge and expertise in application of InterQual criteria interpreting medical policy/benefit information for internal/external customers within the timeframes described in the requirements for URAC and NCQA accreditation as well as department standards.

b. Perform a thorough medical review of records received through suspended claims and provider inquiries to determine medical necessity. May refer to physician for additional review if necessary. Document review outcome. Assure accuracy in benefit administration by demonstrating accurate interpretation and clinical decision making related to medical policy and InterQual criteria and benefit coverage certificates and limitations.

c. Interact appropriately with other care management team members internal/external to Wellmark to meet members needs.

d. Meet both quality assurance and production metrics.

e. Document reviews accurately consistently and timely by following the standard work guidelines and policies to support internal and external processes. Create and send appropriate letter to member/provider with decision of outcome if necessary.

f. Apply consistent accurate interpretation and application of clinical criteria medical policy best practice guidelines and benefit information for medical necessity and medical review decisions as evidenced by attaining specified quality assurance and review scores.

g. Comply with regulatory standards accreditation standards and internal guidelines; remains current and consistent with the standards pertinent to the Medical Review team.

h. Participate in crosscollaboration among care management teams and stakeholders across divisions as required to provide optimal service to the member.

i. Function as back up to other utilization management teams as needed in the following capacity; provide members and health care providers with appropriate and timely prior approval (services procedures Wellmark Health Plan of Iowa Out of Network Referrals) by obtaining medical information necessary to make a clinical determination based on appropriate medical policy or criteria.

j. Provide precertification and continued stay reviews and support to members while located in an acute health care facility skilled or other facility level of care or home health care admissions. In collaboration with facility and member facilitate transition of care planning needs. Proactively identify key issues and barriers to discharge; ensure development and facilitation of a timely discharge plan. Make referrals to Care Management for ongoing longterm needs.

k. Other duties as assigned.

Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other moments that matter as well.  

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit hire train and promote individuals in all job classifications without regard to race color religion sex national origin age veteran status disability sexual orientation gender identity or any other characteristic protected by law.

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