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    Utilization Review Nurse RN - Dubai, United Arab Emirates - ClickJobs

    ClickJobs
    ClickJobs Dubai, United Arab Emirates

    1 week ago

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    Description

    Victorville, CA

    • Coordinates and reviews all medicalrecords, as assigned to caseload
    • Activelyparticipates in Case Management and Treatment Teammeetings
    • Serves as on-going educator to alldepartments
    • Responsible for reviewing patientcharts in order to assess whether the criteria for admission andcontinuation of treatment is being met; gathering data andresponding to request for records from fiscal intermediary;gathering clinical and fiscal information and communicating statusof both open and closed accounts for multiple levels of UtilizationReview and Case Management reporting
    • Able towork independently and use soundjudgment.
    • Knowledge of Federal, State, andintermediary guidelines related to inpatient, acute carehospitalization, as well as lower levels of care for the continuityof treatment.
    • Coordinates discharge referralsas requested by clinical staff, fiscal intermediary, patients, andfamilies.
    • Responsible for providing timely andaccurate referral determination
    • Identificationof referrals to the medical director forreview
    • Appropriate letter language and coding(denials, deferrals, modifications)
    • Appropriateselection of the preferred and contractedproviders
    • Proper identification of eligibilityand health plan benefits
    • Proper coding totrigger the record to be routed to a different work queue or totrigger the proper determination notice to be sentout
    • Responsible for working closely withsupervisor/lead to address issues and delays that can cause afailure to meet or maintain compliance.
    • Meetsor exceeds production and quality metrics.
    • Workdirectly with the provider(s) and health plan Medical Director tofacilitate quality service to the member andprovider.
    • Identifies Clinical Programopportunities and refers members to the appropriate healthcareprogram (e.g. case management, engagement team, and diseasemanagement)..
    • Maintains and keeps in totalconfidence, all files, documents and records that pertain to thebusiness operations.
    • Performs other duties asassigned.

    EDUCATION &EXPERIENCE REQUIREMENTS:

    • CA LVN license required. CA RNlicense preferred.
    • Bachelor's orMaster's degree in Social Work, behavioral or mentalhealth, nursing or other related health fieldpreferred
    • 3 to 5 years of acute care experiencepreferred.
    • Two (2) years managed careexperience in UM/CM Department, preferred

    SKILLS &ABILITIES REQUIREMENTS:

    • Knowledge of CMS, State Regulations,URAC and NCQA guidelines preferred.
    • ICD-9 andCPT coding experience a plus
    • Experiencedcomputer skills with Microsoft Word, Microsoft Outlook, Excel andexperience working in a health plan medical managementdocumentation system a plus
    • Experience inEZ-CAP preferred
    • Medical Terminologypreferred
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