Actalent Northridge , CA 91324
Posted 2 months ago
Description:
The role of the Nurse Reviewer is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests as well as acute inpatient admission
The Nurse Reviewer will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated
If not indicated, Nurse Reviewer will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed
Work in collaboration with the Regional Medical Director to thoroughly review member referral history and anticipated needs in an effort to avoid admission
Responsible for identifying possible TOC cases for new members with high cost diagnosis
The Nurse Reviewer will be responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode as well as prior authorizations (particularly those with facility components)
Identifying the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care
Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting
Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues
Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management
Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting
When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families
Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies
Maintain regulatory Turnaround Time Standards per regulatory guidelines
Document accurately and completely all necessary information in authorization notes
Approve those approvable requests as indicated based on protocols
Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation
Understand all applicable capitation contracts and how they apply to review duties
For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed
When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.)
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner
Participates in "service recovery" through follow-up with an upset patient or provider, gathering information, and demonstrating empathy
Identifies network needs and report to management for potential contracting opportunities
All other duties as directed by management
Skills:
Prior authorization, Utilization review, utilization management
Top Skills Details:
Prior authorization,Utilization review,utilization management
Additional Skills & Qualifications:
Qualifications
Graduate from an accredited Registered Nursing Program or Licensed Vocational Nursing Program
Current California Licenses
Minimum of 1 year acute experience
Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management
Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
Ability to deal with responsibility with confidential matters
Ability to work in a multi-task, fast-paced, high-stress environment
Experience Level:
Intermediate Level
FOR A QUICKER RESPONSE TIME, PLEASE EMAIL ME YOUR RESUME DIRECTLY TO: olellis @actalentservices.com
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion
At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
Hiring diverse talent
Maintaining an inclusive environment through persistent self-reflection
Building a culture of care, engagement, and recognition with clear outcomes
Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.
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