Utilization Review Specialist (RN) Job
HealthPartners
View all jobs from this company

<< Go back

      
Post Date: Jan 24, 2018
Job Type: Full time
Start Date: - n/a -
Salary: - n/a -
Location: US - Minnesota - Bloomington
Job Reference: 86170
APPLY NOW
    Email Job to a Friend
    Save Job to Inbox
    Printer Friendly

Description
Job Description:

We currently have an exciting new opportunity for a Utilization Review Specialist (RN). This position will be:

*

Responsible for prospective, concurrent review and retrospective review authorizations and ongoing management for outpatient/inpatient medical, home health care and skilled nursing facilities.

*

Responsible for reviewing and making timely coverage recommendations based on medical appropriateness, for all products, while maintaining the integrity of each product line.

*

Responsible for applying clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of prior authorization requests, to ensure high quality, cost effective care.

*

Responsible for maintaining a thorough and comprehensive understanding of regulations, member contracts, product lines, HealthPartners policies and procedures in order to serve as a resource for providers, members and internal departments.

*

Serves as subject matter expert on complex medical management issues for internal and external customers.

At HealthPartners, you’ll find a culture where we live our values of excellence, compassion, integrity and most importantly, partnership. By working together, we will improve health and wellbeing, create exceptional experiences for those we serve and make care and coverage more affordable.

ACCOUNTABILITIES:

* Responsible for assessing, monitoring and authorizing services for Procedures, DME, Home Health Care, Rehabilitative, Habilitative, Hospice services, Skilled Nursing facilities and Outpatient services utilizing thorough knowledge of multiple criteria sets and products.
*

Responsible for making coverage determinations and communicating relevant information to physician, providers and members to facilitate utilization management, coordination of care and assist in the claims adjudication process.

*

Responsible for providing member specific utilization management and facilitate discharge planning based on needs of member to include communication between physician, family, providers and vendor to result in appropriate resource utilization while maintaining quality and continuity of care.

*

Responsible for coordinating medical health care between networks, in-plan/out-of-plan contracts

*

Responsible for preparing documentation and consulting with the Medical Director for all potential denials that do not meet medical necessity or HealthPartners criteria. The decision for a medically necessary denial is within the Medical Director role.

*

Responsible for accurately interpreting and correctly applying benefits, networks and product variances and clearly communicating such to members, providers and internal departments.

*

Acts as a liaison between internal and external customers, Marketing, Sales, Claims, Member Services, Nurse Navigators and clinics to resolve systems/process issues.

*

Responsible for assisting Medical Directors in writing coverage decisions that are consistent, sound and defensible.

*

Responsible for determining appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental policies and procedures.

*

Responsible for contacting appropriate physician consultants and medical directors as appropriate.

*

Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to requests of “urgently needed, not yet rendered services” in compliance with state regulations.

*

Efficiently and accurately communicate coverage decisions to members, providers and medical groups, following timelines established by regulations and accreditation standards.

*

Identify and appropriately inform Manager/Supervisor of sensitive or complex cases.

*

Able to negotiate, resolve or redirect when appropriate issues pertaining to differences in expectations of coverage, eligibility and appropriateness of treatment recommendation.

*

Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and member contracts in order to ensure compliance.

*

Response to Member Appeals and MDH (Minnesota Department of Health) inquiries as requested by the Appeals area.

*

Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers.

*

Function as a trainer and mentor for new staff members as requested by Leadership.

*

Ability to work remotely via telecommuting on assigned weekends and holiday.

*

Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI.

*

Perform other duties as assigned.

REQUIRED QUALIFICATIONS:

* Currently licensed Registered Nurse.
* Minimum of three years clinical practice experience as an RN in medical/surgical, critical care, home care, or equivalent knowledge of current hospital and clinical care processes.
* Excellent nursing assessment skills
* Excellent verbal and written communication and interpersonal skills.
* Excellent problem identification and solving skills.
* Ability to organize and prioritize multiple assignments within workload
* Ability to function independently and take independent action, within the scope of job responsibilities.
* Competency in personal computer skills including Microsoft word, Outlook and Internet.

HealthPartners is recognized nationally for providing outstanding care and experience for patients and members. We offer an excellent salary and benefits package. For more information and to apply go to www.healthpartners.com/careers and search for job ID #45254.

Additional Information:

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.



Powered by JOBBEX®