Utilization Review Nurse

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Job Summary:                    The Utilization Review Nurse will support the clinical review operations needed to assist our membership. This position is a member of a team of nurses, physicians, pharmacists, and program coordinators. This role evaluates the efficiency, appropriateness, necessity of the use of medical services, procedures, and facilities. This position is empowered to review medical services with evidenced-based criteria to ensure improved outcomes and appropriate utilization of medical resources based on a patient’s condition.

Responsibilities:

Coordinate with the appropriate case manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning (e.g. Milliman Care Guidelines, Interqual). Performs on-site and/or telephonic concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines. Predicts and plans for patient’s needs from pre-admission, through acute and sub-acute care and post-discharge, in collaboration with the member and providers. Coordinates with appropriate discharge planning with interdisciplinary health care team to coordinate timely discharge. Tracks and reports trends of inappropriate utilization of resources or quality issues to the Medical Director(s). Functions as a major contributor as it relates to discharge planning and readmission reduction strategies. Documents all activities in the appropriate system(s) on a timely basis. Participates in rounds with the Medical Directors from the practice and Health Plans. Monitors and facilitates appropriate utilization of resources using evidenced-based clinical criteria. Participates in an interdisciplinary health care team to achieve positive member outcomes. Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options. Other duties as requested or assigned

Skills and Specifications

• Degree in Nursing from an accredited college
• Required to have education, training or professional experience in medical or clinical practice.
• A current license, without restrictions
• 3-5 years of nursing experience (preferably in utilization management or hospital/acute care).
• Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion; bilingual is a plus.
• Strong work ethic built on a foundation of proactivity and teamwork.
• Ability to navigate ambiguity with the aid of structured problem solving techniques.
• Committed to the practice of inquiry and listening.
• Willingness to “roll up one’s sleeves” and embrace the nitty gritty, bottom up task of building an organization and implementing new initiatives
• Personal and professional track record that demonstrates a commitment to quality in health care
• A positive attitude: ability to work hard, have fun, and operate efficiently in a fast paced, start up, work environment and in a highly complex and dynamic movement for health delivery reform.

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!