Utilization Review Nurse - Impactful Care Coordination

American Health Partners; Franklin (TN); Remote; USD 70,000 - 95,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision 보험 옵션

Generous paid time-off program andpaid

TeleDoc 24/7/365 access to doctors

Optional short- and long-term-disabilt

Employee Assistance Plan (EAP)

401K retirement accounts with company

Employee Referral Bonus Program

Job summary

American Health Plans, a division of American Health Partners Inc., seeks a Utilization Review Nurse to assess medical necessity and quality of care for plan members through pre-service, concurrent, and retrospective reviews.

You will support the Clinical Services Department and Medical Director, ensuring compliance with medical and regulatory guidelines, while collaborating with providers and accrediting bodies.

Qualifications

• Experience in utilization management with a health plan or hospital-based UM department
• Broad knowledge of Medicare regulations and guidance
• Trained in URAC and NCQA principles, policies, and procedures
• Excellent customer service experience
• Strong knowledge of CPT, ICD-10, and HCPCS codes
• Proven ability to problem-solve and make solid decisions

Responsibilities

• Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
• Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
• Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
• Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
• Certify cases that meet clinical review criteria, guidelines and/or screens
• Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
• Refer cases to other professionals internally, including case management and medical consultation when indicated
• Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
• Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
• Other duties as assigned

Skills

Oral and written communication

Self-motivation

Teamwork

Critical thinking

Confidentiality

Tools

InterQual or MCG

Job description

American Health Plans, a division of American Health Partners Inc., seeks a Utilization Review Nurse to assess medical necessity and quality of care for plan members through pre-service, concurrent, and retrospective reviews.

You will support the Clinical Services Department and Medical Director, ensuring compliance with medical and regulatory guidelines, while collaborating with providers and accrediting bodies.