Utilization Review Nurse
Utilization Review Nurse
Posted on :
23-05-2025
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1 Vacancy
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Job Description
Join Martins Point Health Care an innovative notforprofit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values taking care of ourselves and others continuous learning helping each other and having fun are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.
Position Summary
Job Description
The 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.
Utilization Review Nurse 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 evidencedbased 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 postacute 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. Maintains knowledge of applicable regulatory guidelines.
Completes all documentation of reviews and decisions in appropriate systems according to process/ compliance requirements and within timeliness standards.
Participates as a member of an interdisciplinary team in the Health Management Department
May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team
Establishes and maintains strong professional relationships with community providers.
Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
Mentors new staff as assigned.
Maintains quality audit scores within department standards.
Maintains productivity within department standards.
Assists in creation and updating of department policies and procedures.
Participates in quality initiatives committees work groups projects and process improvements that reinforce best practice medical management programming and offerings. Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
Demonstrates flexibility and agility in working in a fastpaced teamoriented environment able to multitask from one case type to another.
Assumes extra duties as assigned based on business needs including weekend rotations.
Utilization Review Nurse Education/Experience:
Unrestricted state license as a Registered Nurse BSN required
3 years of clinical nursing experience as a RN preferably in a hospital setting
Utilization management experience in a health plan UM department
Utilization Review Nurse Required License(s) and/or Certification(s):
Unrestricted state license as a Registered Nurse
Certification in managed care nursing or care management desired (CMCN or CCM)
Utilization Review Nurse Skills/Knowledge/Competencies (Behaviors):
Demonstrates an understanding of and alignment with Martins Point Values.
Maintains current licensure and practices within scope of license for current state of residence.
Maintains knowledge of Scope of Nursing Practice in states where licensed.
Maintains contemporary knowledge of evidencebased guidelines and applies them consistently and appropriately.
Ability to analyze data metrics outcomes and trends.
Excellent interpersonal verbal and written communication skills.
Critical thinking: can identify root causes and understands coordination of medical and clinical information.
Ability to prioritize time and tasks efficiently and effectively.
Ability to manage multiple demands.
Ability to function independently.
Computer proficiency in Microsoft Office products including Word Excel and Outlook.
There are additional competencies linked to individual contributor provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martins Point Health Care Contact us at:
Employment Type
Full-Time
Key Skills
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