NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND
POSITION DESCRIPTION
POSITION TITLE: Medical Review Nurse DEPARTMENT: Medical Management
REPORTS TO: Manager of Utilization and
Clinical Medical Policy HOURS: 37.5
REVIEW TYPE: Annual FLSA: Non-Exempt Exempt
SALARY GRADE: 12 HIERARCHY GROUP: Salary / Exempt / Staff Member
EEOC CODE: Professional WORKERS COMP CODE: Clerical
Warren Study Job Title: Utilization Review/Quality Assurance (WPC 44)
*Fill is contingent on the anticipated increase in Rhody Health Partner membership. If the increase does not occur, we will not fill this position.
Overview:
The Medical Review Nurse works collaboratively with the Health Care Team to determine appropriateness of medical services, procedures, and care setting for Neighborhood members by reviewing and evaluating medical information, and individual needs and applying established national criteria and Neighborhood plan guidelines in order to ensure quality, cost effective care.
Qualifications:
Required:
• Licensed RN, State of RI
• Computer literacy with windows based programs
• Strong organizational and documentation skills
• Excellent Customer Service orientation
• Strong Interpersonal Skills
Preferred:
• 3 years experience in acute care
• Medical/Utilization Review experience
• Case Management experience
• Utilization Review or Case Management certification a plus
• Bilingual (English/Spanish) a plus
Duties and Responsibilities:
Responsibilities include, but are not limited to the following:
• Performs pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hospitals and/or telephonic, using established criteria, Neighborhood plan benefit guidelines, and clinical judgment, to determine appropriateness of medical services, procedures, and care setting
• Refers and discusses complex case or cases that do not meet established criteria and guidelines with the physician advisor
• Communicates with hospital staff, including but not limited to, physicians, case managers, and rehabilitation therapists, to ensure timely discharge planning and placement in most appropriate setting.
• Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual patient
• Reviews requests for conditional benefits and utilizes established Neighborhood clinical guidelines to determine medical necessity. Presents to physician advisor for authorization decision as necessary
• Identifies high-risk members and initiates appropriate referrals to case management, COB/TPL staff, HCCT, etc.
• Collaborates with peers internally and externally to continually ensure member’s health care needs are being met in accordance with NHPRI benefit plans, and through identification of agreed upon alternatives
• Reviews pended claim requests as assigned by team leader to determine medical necessity and appropriate payment
• Calculates cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc…)
• Communicates with ancillary departments, such as the Customer Service Center, as necessary to meet individual needs of members and providers
• Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner
• Takes responsibility for professional development, supports a learning environment, and meets professional competency requirements
• Participates in department continuous quality improvement activities
• Other duties as assigned by Manager
Neighborhood is an EOE /M/F/D/V
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