Utilization Review Nurse (Registered Nurse/RN) - Health Alliance Plan - Troy

The Utilization Review (UR) Nurse ensures services meet member’s health needs and promotes the provision of high quality care in the most appropriate and cost-effective setting by identifying, assessing, planning, coordinating, monitoring, and evaluating healthcare services, outcomes, and managing the utilization of Health Alliance Plan (HAP) benefits through activities of medical utilization review and discharge planning.  This individual promotes collaboration with the patient care team, such as the Outpatient Case Management team, to ensure a high quality of patient care, reduced length of stay, efficient utilization of resources, and appropriate reimbursement of care and services, including discharge planning assistance and aftercare support.  Time may be split between project work and performing clinical reviews.

DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Responsible for coordination of daily Utilization Management functions in accordance with Health Alliance Plan policies and procedures.
• Facilitate access of healthcare services for members and guide appropriate direction of member’s utilization of healthcare services to the PCP’s affiliated hospital network.
• Provide liaison services to members and providers. Represent Health Alliance Plan in the community to peers, physicians and providers as a professional and HAP member advocate.
• Have knowledge of Health Alliance Plan lines of business and operations and assist in their coordination. Perform quality audits and identification of COB through data collection and interpretation.
• Educate the member, family, providers and community support services on Health Alliance Plan guidelines, policies, benefits, hospital networks and available HAP services such as Case Management and Disease Management.
• Participate in the development of alternative cost savings and quality management processes that include inpatient and outpatient utilization.
• Refer cases to Physician Advisors and/or HAP Medical Directors when appropriate, where utilization and quality issues are identified and facilitate issuance of denial of medical necessity and/or benefit letter to member or responsible party within regulatory timeframes.
• Collect, analyze and interpret data for trending, reference, problem identification   and problem solving, preparation of utilization data and follow-up on issues with the involved parties.
• Responsible for on-call duty on rotational basis as assigned for membership/provider needs according to the department’s schedule.
• Conduct admission, concurrent, post-service and readmission review for all hospital requests related to HAP members.
• Arrange for member transfers when appropriate.
• Identify appropriate alternative care options available for all admissions and assist in their use.
• Review retrospective case requests for medical necessity and obtain additional documentation as required.
• Provide assistance to physicians and hospital staff with discharge planning to expedite hospital discharge.
• Educate providers about inpatient and outpatient cost-effectiveness, alternative placement and quality management.      
• Assist HAP Medical Directors with review of cases and application of medical necessity criteria. Discuss identified variances or specific members that do not meet criteria for appropriate level of care.
• Assist Medical Services department in the collection of medical information, such as HEDIS measures.
• Use established medical criteria to approve services based on information obtained from hospital UR departments, attending physician and/or other providers. Reviews inpatient admissions, continued stays and specific ancillary services telephonically or by other electronic means for LOS, medical necessity, discharge planning and care coordination meeting all NCQA timelines.
• Ensure full collection of clinical information prior to rendering a decision including contacting hospital providers for additional information as necessary.
• Manage workload needs on a concurrent basis, including readmission, authorization queues and fax queues inventory in the UR department to concurrently prioritize self-assignment for greatest impact on department function.
• Support orientation program for UR staff by acting as primary mentor for review nurse and physician reviewers.
• Collaborates with the Disease Management, Quality Management, & Case Management departments in the development of protocols and guidelines designed to standardize care practice and care delivery.  Seeks out opportunities to improve HEDIS, NCQA or general accreditation and Quality Improvement activities with development of action plans.
• If services are denied, accurately documents this process and provides timely facility and member notifications following specified timelines (regulatory or NCQA) and department protocols.
• Communicates with all departments regarding issues related to length of stay and care coordination.  Interacts with departments identifying variances to care coordination and specific payment and level of care situations throughout the continuum of care.
• Inform providers of Medical Director’s decisions within regulatory timeframe. Assist external providers in coordinating discharge plans.·        
• Reviews utilization patterns, identifies trends and problem areas for special studies.Through continuous assessment, screens the appropriateness of services, the utilization of healthcare resources and the quality of patient care in accordance with federal, state, third party payer requirements and accreditation/licensure standards.
• Identifies and determines medical necessity of out of network requests for services.
• Meets productivity standards as established by department needs and metrics.
• Meets department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. Expectation is obtainment of score >90% for all quarterly review scores after 90 days of employment.
• Answers incoming calls from a phone queue center and from support staff to appropriately advise callers and/or enters the request into the software system.
• Coordinates peer-to-peer conversations with the Medical Director and provider at the time of the request.
• Other duties as assigned.