Concurrent Nurse Reviewer, Facility Utilization Review Unit

Employment Type: Full-time, Exempt

Pay Range: $59,000 to $116,000 (Individuals typically begin between the minimum to middle of the pay range)

About the Role

Under minimal supervision, conducts detailed analysis and review of inpatient hospital stays and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits, and nationally-accepted clinical guidelines to determine appropriateness of care for all HMSA members.

Qualifications

• Associate’s Degree in Nursing
• Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN
• Two (2) years clinical care experience or case management or related experience
• Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures
• Good typing skills
• Strong organizational skills
• Good communication skills both verbally and written
• Multi-tasking skills
• Critical thinking skills
• Basic knowledge of Microsoft Office applications (Word, Excel, Outlook)
• Currently licensed in Hawaii as an RN or LPN (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

Responsibilities

• Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations as described in the Medical Management UM work plan
• Determines inpatient hospital stays as medically appropriate for the member's clinical condition or refers to a Medical Director for potential denial
• Follows each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admission
• Uses effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
  • Promote improved quality of care and/or life
  • Promote cost-effective medical outcomes
  • Prevent hospitalization when possible and appropriate
  • Promote decreased lengths of hospital stays when appropriate
  • Ensure the quality of care member is receiving during hospital stay is appropriate
  • Ensure appropriate levels of care are received by patients
• Consults with Medical Directors on potential quality issues encountered during review of medical records when complexity requires further review or intervention
• Follows up with attending physicians, hospitalists, or other facility staff
• Provides appropriate consultation and referral to Case Management or QUEST Integration program as needed
• Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing each case to fully utilize all available inpatient and community resources
• Identifies cost savings and accurately records all communications and interventions
• Evaluates suspended claims against medical records to determine medical necessity and appropriateness of medical services, identifying irregularities such as over or under-utilization of services, potential up-coding, overbilling, etc.
• Communicates timely, accurate information either verbally or in writing using clinical judgment, knowledge of medical/reimbursement policies, and plan benefits to internal MM staff, other internal departments (Claims Administration, Customer Relations, etc.), providers, members, and other authorized persons
• For denied services, ensures the denial, benefit, and appeal language are accurate and consistent with department procedures, accreditation, and regulatory guidelines
• Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed
• Identifies and refers quality of care issues and suspected fraud, waste, or abuse to the appropriate departments
• Performs all other miscellaneous responsibilities and duties as assigned or directed