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

    ClickJobs
    ClickJobs Dubai, United Arab Emirates

    19 hours ago

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    Description

    Victorville, CA

    • Coordinates and reviews all medical records, as assigned to caseload
    • Actively participates in Case Management and Treatment Team meetings
    • Serves as on-going educator to all departments
    • Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
    • Able to work independently and use sound judgment.
    • Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
    • Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
    • Responsible for providing timely and accurate referral determination
    • Identification of referrals to the medical director for review
    • Appropriate letter language and coding (denials, deferrals, modifications)
    • Appropriate selection of the preferred and contracted providers
    • Proper identification of eligibility and health plan benefits
    • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
    • Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
    • Meets or exceeds production and quality metrics.
    • Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
    • Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
    • Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
    • Performs other duties as assigned.

    EDUCATION & EXPERIENCE REQUIREMENTS:

    • CA LVN license required. CA RN license preferred.
    • Bachelor's or Master's degree in Social Work, behavioral or mental health, nursing or other related health field preferred
    • 3 to 5 years of acute care experience preferred.
    • Two (2) years managed care experience in UM/CM Department, preferred

    SKILLS & ABILITIES REQUIREMENTS:

    • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
    • ICD-9 and CPT coding experience a plus
    • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
    • Experience in EZ-CAP preferred
    • Medical Terminology preferred
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