Utilization Review Nurse - Part Time

Weld County Government Greeley , CO 80634

Posted 3 days ago

Description

Determines eligibility for Medicaid long term home health clients and authorizes appropriate services. Provides support to the case management team around utilization of home health services.

PLEASE NOTE

Position is up to 10HRS a WEEK

Position is considered NON-BENEFITED

OPEN UNTIL FILLED.

Essential Duties and Responsibilities

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned. (Any one position may not include all of the duties listed nor do the listed examples include all duties which may be found in positions of this class.)

Complete comprehensive face to face functional assessments with clients in their home as is mandated by need and regulations to determine eligibility for long term home health services.

Review prior authorization requests (PARS) and home health care plans submitted by home health agencies for appropriateness of skilled care to be provided to Medicaid clients. Consult with home health agency staff, physicians and other medical professionals, and/or clients and families to aid in determination of appropriateness of services and medical necessity.

Refer clients to appropriate community resources to assist in meeting client needs.

Make all home health service denials in cases where services do not meet the medical necessity and/or level of care criteria under program requirements and participate in appeal hearings.

Assist case management staff in the determination of appropriateness of long term care services and medical necessity as needed. Assist in covering case management tasks for new referrals from the Intake Unit as well as for ongoing cases as needed.

Accurately establish and maintain client physical and digital files in accordance to SEP contract and program regulations including maintaining all standards related to the Benefits Utilization System (BUS). Maintain all standards related to client confidentiality and HIPAA regulations.

Qualifications

MINIMUM QUALIFICATIONS

Required Education:

  • Successful completion of a two-year RN or Bachelors Degree in nursing.

  • Must possess a current Colorado Nursing License.

Preferred Work Experience:

  • Experience as a nurse in a home health care or nursing home setting.

  • Experience working with a diverse population including disabled individuals of all ages, aging populations and individuals with behavioral mental health needs.

  • Experience working with or knowledge of community resources and other community based services for the aging or disabled population.

  • Experience performing needs assessments and/or care planning for individuals.

Required Skills, Knowledge and Abilities:

  • Must have a valid Colorado Driver's License and Liability Insurance. Must provide own transportation and be willing to travel throughout Weld County.

  • Must pass Human Services Background Checks.

Other Necessary Requirements

ADDITIONAL REQUIREMENTS

Ability to enter data into several different computer programs. Ability to learn and apply new computer skills on a regular basis. Knowledge of computer programs such as Microsoft Windows and Word, Excel, and Outlook.

Ability to read and comprehend instructions, correspondence and department policies and procedures. Ability to write correspondence.

Ability to effectively communicate in one-on-one and small group situations to customers, clients and other employees of the organization.

Ability to apply math concepts and calculations in the work environment.

Ability to apply common sense to problem solve in a work environment.

Ability to adapt to fast paced, high volume and ever-changing work environment and be able to handle high stress situations.

Attend meetings, trainings, and conferences related to SEP programs administered and clients served.

Ability to stay informed of and comply with latest rules, regulations, and legislative issues that may impact the Long-Term Care System and attend all appropriate local and state meeting, committees, workshop and conferences.

Follow Human Services policies and procedures, the Weld County Code of Conduct and adhere to strict confidentiality guidelines and appropriate release of information outlined in both. Adhere to strict confidentiality guidelines and appropriate release of information.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee may be required to sit for extended periods of time and is occasionally required to stand and walk. Occasionally the employee may be required to lift and/or move heavy files or objects up to 25 pounds. The employee frequently is required to use their hands and reach with hands and arms. Specific vision abilities required for this job include close vision, distance vision, peripheral vision, and ability to adjust focus such as that used when using a computer or reading.


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Utilization Review Nurse - Part Time

Weld County Government