Utilization Review Nurse: Care Quality Advocate

American Health Partners; Franklin (TN); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision

Generous paid time-off

TeleDoc access

Disability plans

Employee Assistance Plan

401K with company match

Employee Referral Bonus

Job summary

American Health Plans, a division of American Health Partners Inc., is seeking an experienced Utilization Review Nurse to support the Clinical Services Department in Franklin, Tennessee. You will assess medical necessity, quality of care, and appropriate level of care for plan members, using InterQual or MCG criteria.

Collaborate with the Medical Director and providers, perform pre-service, concurrent, and retrospective reviews, and ensure compliance with regulatory timelines while delivering

Qualifications

• 1+ year of utilization management experience with a health plan or hospital-based UR department.
• Clinical certification (CCM) is a plus.
• Strong knowledge of Medicare regulations and CPT/ICD-10/HCPCS codes.

Responsibilities

• Assess medical necessity, quality of care, level of care and appropriateness of health care services for plan members.
• Identify placement settings with autonomy and appropriate restrictions based on medical necessity.
• Conduct outreach to requesting providers to gather clinical data.
• Apply clinical review criteria and determine medical necessity.
• Certify cases that meet criteria and consult with physicians when needed.
• Refer cases to other professionals internally as indicated.
• Adhere to regulatory timeframes in all UM review processes.
• Escalate potential risk issues to the Director of Medical Management as needed.

Skills

Utilization management

RN license

InterQual/MCG knowledge

Medicare knowledge

URAC/NCQA awareness

Education

Registered Nurse license

Tools

InterQual criteria

MCG guidelines

Job description

American Health Plans, a division of American Health Partners Inc., is seeking an experienced Utilization Review Nurse to support the Clinical Services Department in Franklin, Tennessee. You will assess medical necessity, quality of care, and appropriate level of care for plan members, using InterQual or MCG criteria.

Collaborate with the Medical Director and providers, perform pre-service, concurrent, and retrospective reviews, and ensure compliance with regulatory timelines while delivering