Retrospective Review Nurse

Location: Sacramento, CA
Date Posted: 04-23-2018
Retrospective Review Nurse (RN or LVN) – Managed Care
Sacramento, CA
Your Job Summary:
As a Retrospective Utilization 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 retrospectively review inpatient and outpatient treatments that had not been cleared through the prior authorization or pre-certification process. 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 Retrospective Review Nurse will evaluate the options and services required to meet the member’s health needs, in support and collaboration with disease management interventions.  If needed, the nurse may perform prospective or concurrent review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests.
Your Background
Current, valid, and unrestricted state Registered Nurse (R.N.) or Licensed Vocational Nurse (L.V.N.) license.
CCM or CPUR/CPUM or similar certification is preferred
Roughly 2-4 years acute care clinical nursing experience is required.
Around 1-2 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 retrospective reviews on all inpatient, facility and appropriate home health services.  Monitor level and quality of care for members. Develop and maintain positive relationships with providers, members and caregivers through collaborative problem solving during telephonic or onsite visits.  Perform Utilization Review retrospectively 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.   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.
443.552.7423 (CALL – TEXT – FAX)

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