JOB Under the direction of the Manager, UM, this position will review requests for medical services against National Clinical Guidelines. The UM Nurse uses judgment in selecting appropriate guidelines and in applying general policies and procedures.
Responsible for assuring the receipt of high quality, cost-efficient medical outcomes for those enrollees identified as having the need for inpatient and/or outpatient precertification / preauthorization. Responsible for screening enrollees for initiatives and programs including Case Management and Disease Management.
EXAMPLE OF DUTIES •Review precertification requests for medical necessity, referring to the Medical -Director those that require additional expertise.•Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.•Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.•Use 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- prevent complications in patients under our care when possible- provide for continuity of care- assure appropriate levels of care are received by patients•Provide appropriate referrals to Case Management.•Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.•Maintain accurate records of all interventions.•Performs utilization review for all members requiring services requiring authorization.•Conducts assessment of medical necessity utilizing MCG online criteria.•Gathers all pertinent information from providers and facilities to ensure GCHP physician reviewers have sufficient information to make a decision to approve or deny services.•Coordinates with non-clinical staff to ensure all documentation is completed timely and in a professional manner.•Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider. SUPPLEMENTAL INFORMATION Special Requirements Must be able to sit, stand, bend, reach overhead and lift up to 10 pounds; travel outside of the office and/or attend meetings both during and after normal work hours, both at or away from the work site.
