Concurrent Nurse Reviewer - Facility Utilization Review Unit

Employment Type

Full-time Exempt

Job Summary

Hybrid Work Environment - Must reside in Hawaii
Pay Range: $59,000 - $116,000
Note: Individuals typically begin between the minimum to middle of the pay range

About the Role

Conducts detailed analysis and review of inpatient hospital stays and suspended claims, 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.

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 whether the stay requires referral 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.
• Promotes improved quality of care and/or life, cost effective medical outcomes, prevent hospitalization when possible and appropriate, and ensure appropriate levels of care are received by patients.
• Consults with Medical Directors on potential quality issues encountered during review of medical records in situations when the complexity of the member's medical, surgical and/or pharmaceutical management is unclear and may require further review or intervention.
• Provides appropriate consultation and referral to Case Management or QUEST Integration program as appropriate.
• Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed. Also 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.

Requirements

• Associates Degree in Nursing
• Two 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: Typing speed of 40 wpm
• Strong organizational skills
• Good communication skills: verbal and written
• Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and 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)