UM Escalation Nurse

EXL - Tampa, FL3.8

Full-timeEstimated: $75,000 - $97,000 a year
SkillsBenefits
Overview
Why join EXL?
At EXL, were more than just an analytics, operations management, and technology Company. We focus not only on our outstanding Team Members, but on our growing industry as well.
Headquartered in NYC, EXL has more than 27,000 professionals situated in locations throughout the United States, Europe, Asia, Latin America, and South Africa.

Our EXL Team Members receive the benefit of:Valuable Compensation Package:
  • Competitive Wages
  • Work-Related Expense Reimbursement
  • Annual Discretionary Bonuses
  • Team Member Referral Bonuses
Comprehensive Health & Welfare Benefits:
  • Group Medical, Dental and Vision Benefits
  • Flexible Spending Accounts and Health Savings Accounts
  • Generous Paid Time Off, Sick Days and Holiday Pay
  • Group Life Insurance, LTD and 401k Retirement
Inviting Culture & Team-Oriented Philosophy:
  • Exciting Work Environment
  • Casual Dress Code
  • Monthly Team and Company Events
  • Team Member Appreciation Awards
  • Remote, Home-Based Opportunities
  • Opportunities for Upward Mobility
The UM Escalation Clinical Reviewer is a highly skilled nurse clinician who provides a second level of clinical review prior to sending cases to the physician peer reviewer for a possible adverse determination for initial and appeal decisions. This position will ensure that all contractual and regulatory requirements are met, and all clinical review protocols are adhered to. in accordance with Utilization Management Policies and procedures. The position will review clinical information submitted with the clinical case or appeal, and will approve if the case meets medical necessity criteria based on the information received, including any new information submitted from the provider. If the case is not approvable, the UM Escalation Clinical Nurse Reviewer will prepare the case for submission to the appropriate peer reviewer, ensuring that timeliness standards are met. The Clinical Reviewer I will receive the physician peer review response, and coordinate the appropriate medical record documentation and notifications to the members and providers, as required by regulatory and accreditation guidelines and client specific requirements. This position is very independent, will be responsible to apply clinical judgement within the scope of his/her license, and must be able to self-manage tasks and time based on defined turnaround times and client regulations.

Responsibilities

Job Performance/Responsibilities:
  • Reviewing clinical cases that are not approved at initial review, including cases recommended for physician peer review for initial and, appeal decisions.
  • Ensure that all regulatory and accreditation standards are met for initial and appeal reviews, in regards to criteria selection, timeliness and notifications to members and providers.
  • Works with physician and clinical review teams to ensure that verbal and written notifications to providers and members are linguistically and culturally appropriate, and compliant with regulatory and accreditation standards.
  • Serve as a clinical resource to initial review and other clinical staff in regards to UM review protocols and interpretation of clinical information
Ensures that external requests for peer to peer conversations between external physicians and HI physician reviewers are documented, scheduled and coordinated, in accordance with HI protocols for peer to peer reviews, and that outcomes of these discussions are documented and effectuated appropriately.

  • Processes reviews using InterQual, MCG criteria, CMS guidelines or any other designated criteria or guidelines designated by Health Integrated.
  • Participates in UM program CQI activities
  • Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
  • Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
  • Communicates all UM review outcomes in accordance with the health plan client profile procedures
  • Follows relevant client time frame standards for conducting and communicating UM review determination
  • Maintains and submits reports and logs on review activities as outlines by the UM program operation procedures and in accordance with Letters & Appeals Policies
  • Identifies and communicates to HI Clinical Leadership all potential quality of care concerns
Customer Services – Internal:
  • Supports a positive working environment;
  • Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Clinical Leadership, as a resource;
  • Communicates to the Sr. Manager of UM all problems, issues and/or concerns as they arise
  • Communicates to the Sr. Manager of UM any issues or concerns related to quality of care, using the Health Integrated procedures
  • Maintains a courteous and professional attitude when working with all Health Integrated staff members and the management team;
  • Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role and
  • Actively participates in team meetings, as designated.
  • Performs other duties as requested by Management.
Customer Service – External
  • Timely identifies and communicates to applicable practitioners, providers and the health purchaser staff all issues and concerns related to the case at hand
  • Communicates to the client/health plan staff any issues or concerns related to quality of care, using Health Integrated policies/procedures.
  • Works, communicates and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated;
  • Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and
  • Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), providers (s), patient/patient’s legally appointed representative any UM coverage determination(s).
Qualifications
Education/License/Certification: RN with a current, unrestricted license to practice as a health professional in a state or territory of the United States required.
Experience: 3 years of experience in Utilization Management, or other cost management programs preferred. One to two years directly related experience using evidence based criteria or nationally recognized healthcare criteria preferred. Two (2) years experience in hospital-based nursing or medical-surgical care experience preferred for positions in medical management areas or behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred.

  • Knowledge/Skills:
  • Strong verbal and written communication skills,
  • clinical and critical thinking skills essential.
  • Highly knowledgeable of principles of Utilization Management, including accreditation and regulatory standards
  • Able to use clinical judgment in case review
  • Strong problem solving and decision-making skills essential.
  • Strong typing and computer skills essential.
EEO Statement
EEO/Minorities/Females/Vets/Disabilities