Job Summary: The ISNP Utilization Management Nurse is supervised by a Utilization Management Supervisor and is responsible for evaluating a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for inpatient and outpatient services based on independent analysis of those medical records and application of appropriate medical necessity criteria. The ISNP Utilization Management Nurse is empowered make clinical determination decisions by independently authorizing services deemed medically necessary based on the independent review using InterQual, MCG, National and Local Coverage Determination Guidelines and to refer and consult with a medical director for those services that do not meet medical necessity criteria. The ISNP Utilization Management Nurse directly interacts with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria and policies for the company and its customers, as well as assisting management with development of short- and long-term business objectives. Throughout the performance of their duties, the ISNP Utilization Management Nurse provides a front-line regulatory/compliance function in their evaluation and application of the criteria. The ISNP Utilization Management Nurse is supported by administrative staff responsible for compiling information, data entry and other tasks to build cases and facilitate their work so that the ISNP Utilization Management Nurse can focus the majority of their time on applying their medical knowledge to medical necessity reviews. This job description is intended to provide a general overview of the position, while recognizing that actual day-to-day duties may vary for the ISNP Utilization Management Nurse depending on individual factors such as education, experience, skills, supervisor, and caseload.
Key Tasks and Responsibilities: Receives requests for authorization of services, including inpatient hospital admissions, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination) in the Health Plan designated system accurately and timely. Verifies and documents member eligibility for services. Communicates and interacts on a real time basis via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es). Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities. Applies Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral. Applies submitted information to Plan authorization process (utilizing Interqual, MCG, NCDs, LCDs or medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines. Coordinates with the referral source if insufficient information is available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan process for requesting additional information. Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested. Documents case activities for Utilization determinations and discharge planning coordination in Plan IT system in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy. Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner and saves in the appropriate system defined area. Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review) Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements. Recognizes opportunities to obtain input from assigned care coordination/Advanced Practice Provider and refers accordingly. Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management. Participates in the appeals process. Maintains awareness and complies with Plan authorization timeliness standards based on Health Plan/NCQA requirements. Actively participates in weekly review of extended hospital stay members and provides clinical updates and discharge planning needs to the team.
Supervisory Responsibilities: There are no supervisory responsibilities for this position. Credentials & Coverage: Licensed as a nurse. Registered Nurse Preferred. Valid state driver’s license with a good driving record and proof of automobile insurance required. Auto liability insurance coverage per minimum required by home state.
Education and Training: Associate’s degree in nursing required, bachelor’s degree preferred.
Knowledge and Experience: 3-5 years’ experience as a nurse. Minimum of 2 years Health Plan utilization management experience OR equivalent. Excellent verbal and written communication skills. Excellent computer skills, Clinical Platform/MS Office Products. Minimum of one year of supervisory experience in leading a team.
