Concurrent Review RN - Health Plan

Location: Phoenix, AZ
Date Posted: 02-01-2018
Concurrent Review Nurse (RN) - Managed Care
Phoenix, AZ (centrally located near the Biltmore area)
Your Job Summary:
As a Concurrent Review Nurse you will utilize your clinical skills to review and monitor members’ utilization of health care services with the goal of maintaining high quality cost-effective care for health plan members that are hospitalized in acute, skilled and long term care settings.  You will telephonically review inpatient and outpatient treatments and assist with the coordination of discharge planning needs. You will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.  The Concurrent Review Nurse will evaluate the options and services required to meet the member’s health needs, in support and collaboration with disease management interventions.  The nurse will perform prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests.
Your Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Your Background
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
CCM or CPUR/CPUM/CPHM or similar certification is a plus
Roughly 2-4 years acute care clinical nursing experience is required.
Around 1-3 years’ experience in utilization management, concurrent review, or retrospective review at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Your Duties:
Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.  Monitor level and quality of care for members.  Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.   Assist with establishing initial care plans, assisting in the coordination of care through the health care continuum.  Develop and maintain positive relationships with providers, members and caregivers through collaborative problem solving during telephonic or onsite visits.  Perform Utilization Review pre-authorization, concurrent and retrospective review as needed for inpatient or outpatient services and predetermination reviews.  Collect pertinent documentation and conduct medical services review applying appropriate criteria, including national standardized criteria and local plan rules and guidelines.  Perform discharge planning activities in coordination with facility or provider case manager.  Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan.  Consult with Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval.  Make referrals as indicated to case management, disease management, or behavioral health.  Maintain open communication flow with internal Disease Review, Complex Case Management, or Social Services staff to facilitate smooth transition and follow-ups as member is transferred from one level of care and/or service to another.   Analyze all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identify potentially high cost, complex cases for high level case management intervention. For short-term cases, conduct a thorough and objective assessment of the member’s current status including physical, psychosocial, environmental, and gather all information pertinent to the case. Develop, implement and monitor a care plan through the interdisciplinary team process in conjunction with the individual.  Collaborate with the Disease Management, Quality Management, and Utilization Management departments in the development of protocols and guidelines designed to standardize care practice and delivery.  Perform other related tasks as assigned by supervisor or manager.
CareNational Healthcare Services
480.478.1635 (CALL – TEXT – FAX)
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