LPN Utilization Review Nurse

High Point & Affiliated Organizations; New Bedford (MA); On-site; USD 75,000 - 115,000; Full time

Job summary

High Point & Affiliated Organizations is seeking a UR Nurse to oversee utilization management for insured inpatient services. Strong knowledge of ASAM criteria, managed care, and medical necessity guidance are essential.

The role requires excellent organizational skills, attention to detail, and professional patient- and family-facing communication. Responsibilities include obtaining necessary licensure, complying with Federal Regulations and HIPAA, coordinating authorizations, conducting

Qualifications

• Knowledge of ASAM criteria
• Experience in utilization management
• Understanding of medical necessity and ethics
• Strong communication and teamwork

Responsibilities

• Maintains and submits any current Licensure or Certificate necessary for the performance of the position.
• Compliance with Federal Regulations, 42 CFR Part II, Confidentiality of Alcohol and Drug Abuse Patients and HIPPA.
• Utilization management of all patients, ensuring proper authorization is obtained for all insured inpatient services.
• Clinical reviews with insurance companies for continued stay, step downs to lower level of care, and step ups to higher level of care (except IPU).
• Responsible for assuring that the business office receives accurate billing information in a timely manner.
• Keep counselors / nurses of insured patients updated as to their status.
• Attend daily multi-disciplinary treatment team meetings.
• Obtain necessary clinical, medical, and treatment information from clinical and medical staff to provide a comprehensive concurrent review.
• Review all new admissions daily, verifying insurance eligibility, level of care, and obtaining all applicable authorizations.
• Complete discharge summary information to insurance companies when applicable.
• Assist with admission approvals as needed.
• Attend mandatory meetings and trainings.
• Attend monthly departmental meetings.
• Responsible for continued education in the field of substance abuse, nursing and related courses, when necessary.
• Coordinate and support the initiation and completion of all appeal processes as necessary for insurance claim denials and/or retrospective reviews.
• Provide assistance and support on the unit when necessary.
• Utilize standard precautions at all times.
• Demonstrate behaviors that recognize the rights of patients as defined by the patient rights.
• Other duties as assigned by the supervisor.

Skills

ASAM criteria

Managed care

Organizational skills

Attention to detail

Medical necessity

Ethics

Customer service

Verbal communication

Written communication

Team collaboration

Psychiatry and addictions knowledge

Professional demeanor

Problem solving

Critical thinking

TB screening

HPAO de-escalation training

Tools

Microsoft Office

Electronic Medical Records

Job description

UR Nurse Requirements

• Knowledge of ASAM criteria
• Managed care and utilization management experience
• Able to organize and structure own workload, attention to detail, and ability to maintain up-to-date tracking and filing systems
• Good clinical judgment, understanding of medical necessity and evidence-based practices
• Understanding of boundaries and ethics
• Possesses a pleasant telephone manner and customer service skills
• Good verbal and written communication skills
• Ability to work collaboratively with others in a collaborative and cooperative manner
• Understands the diseases of psychiatry and addictions and treatment modalities
• Presents professional at all times and allows for flexibility
• Problem solving abilities
• Critical thinking skills
• TB screening
• Certification in HPAO De-escalation training
• Knowledge of computer programs including Microsoft Office and Electronic Medical Records

UR Nurse Duties and Responsibilities

Maintains and submits any current Licensure or Certificate necessary for the performance of the position.

Compliance with Federal Regulations, 42 CFR Part II, Confidentiality of Alcohol and Drug Abuse Patients and HIPPA.

Utilization management of all patients, ensuring proper authorization is obtained for all insured inpatient services.

• Clinical reviews with insurance companies for continued stay, step downs to lower level of care, and step ups to higher level of care (except IPU).
• Responsible for assuring that the business office receives accurate billing information in a timely manner.
• Keep counselors / nurses of insured patients updated as to their status.
• Attend daily multi-disciplinary treatment team meetings.
• Obtain necessary clinical, medical, and treatment information from clinical and medical staff to provide a comprehensive concurrent review.
• Review all new admissions daily, verifying insurance eligibility, level of care, and obtaining all applicable authorizations.
• Complete discharge summary information to insurance companies when applicable.
• Assist with admission approvals as needed.
• Attend mandatory meetings and trainings.
• Attend monthly departmental meetings.
• Responsible for continued education in the field of substance abuse, nursing and related courses, when necessary.
• Coordinate and support the initiation and completion of all appeal processes as necessary for insurance claim denials and/or retrospective reviews.
• Provide assistance and support on the unit when necessary.
• Utilize standard precautions at all times.
• Demonstrate behaviors that recognize the rights of patients as defined by the patient rights.
• Other duties as assigned by the supervisor.