Utilization Review Nurse

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Responsible for performing Workers’ Compensation utilization review, which includes prospective, concurrent, expedited, and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence-based criteria. Through the discharge planning process, identify patients with ongoing case management needs and refer these claimants to the Case Management team for outreach and follow-up.

Essential Duties and Responsibilities:

• Conducts first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests
• Reviews of all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
• Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate. Reviews must be conducted within state jurisdiction and URAC timeframes.
• Review length of stay for inpatient cases when applicable
• Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating of services
• Identify & review with Medical Director any case with potential safety issues
• Promote cost-effective health care with an aligned health provider network
• Identify and refer to Telephonic Case Management / Pharmacy TCM
• Coordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals
• Manage determinations within the pharmacy portal
• Perform NY PAR in the onboard system in accordance with NY MTG Guidelines

Additional Functions and Responsibilities

• Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards
• Maintain established template documentation standards adhering to URAC standards and company policies and procedures
• Maintain minimum billing and report billing hours in accordance with case activity and billing practices
• Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHI
• Other job duties as assigned