Utilization Review Nurse: Health Plan Case Management

CHRISTUS Health; Alamogordo (NM); Sur place; USD 70 000 - 90 000; Plein temps

Résumé du poste

CHRISTUS Health is seeking an Utilization Review Nurse in the United States (Alamogordo, NM) to assess medical necessity and manage hospital resource utilization. This role involves pre-admission, concurrent, and retrospective reviews with InterQual/MCG/CMS guidance, ensuring proper coverage and coordinating with providers and insurers.

The ideal candidate has a nursing degree (ADN or BSN preferred) and 3–5 years of nursing experience with proficiency in Microsoft Office.

Qualifications

• Graduate of an accredited school of vocational nursing or equivalent required.
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred.
• 3–5 years of nursing experience preferred.

Responsabilités

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
• Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
• Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate.
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after hour calls to meet business requirements as needed.

Connaissances

Communication skills

Clinical judgment

Critical thinking

Microsoft Office

Formation

Associate’s degree in Nursing (ADN)

Bachelor’s degree in Nursing (BSN)

Outils

Outlook

Teams

Word

Excel

Description du poste

CHRISTUS Health is seeking an Utilization Review Nurse in the United States (Alamogordo, NM) to assess medical necessity and manage hospital resource utilization. This role involves pre-admission, concurrent, and retrospective reviews with InterQual/MCG/CMS guidance, ensuring proper coverage and coordinating with providers and insurers.

The ideal candidate has a nursing degree (ADN or BSN preferred) and 3–5 years of nursing experience with proficiency in Microsoft Office.