Intermountain Healthcare Utilization Review Nurse - SelectHealth in Murray, Utah
Greater Salt Lake area
What does it mean to be a part of Intermountain Healthcare? It means that the quest for clinical excellence is not just a goal, but a given. It means building an environment where physicians and employees can deliver the best in healthcare. And it’s realizing each employee or volunteer is vital to the healing process, because we can only achieve theextraordinary together .
Being a part of Intermountain Healthcare means joining with a world-class team of over 36,000 employees and embarking on a career filled with opportunities, strength, innovation, and fulfillment. Our mission is: Helping people live the healthiest lives possible.
Our patients deserve the best in healthcare, and we deliver.
Interested in joining the SelectHealth team? Watch the video at the end of this posting to see what being a RN Care Manager at SelectHealth is all about!
The Utilization Review (UR) Nurse is responsible to review clinical records and make sure the request meets the criteria established by CMS, Medicaid, InterQual or SelectHealth’s internal policies. The UR nurse works closely with the provider to make sure they have all the information required to make the decision on a request.If the request does not meet the criteria, the RN can contact the provider for additional information. If none is available, the case will be sent to MD review where subject matter clinicians review the case. The providers that do our MD reviews have extensive medical background in addition to our specialty reviewers that may be OT or PT specialists.UR nurses interface with the providers more than the individual members.
Essential Job Duties
- Analyze and evaluate medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification standards.
- Implement utilization management processes and coordinate medical services with other SelectHealth and Intermountain departments, as well as local, state and federal programs (Medicare, Medicaid, etc.)
- Review outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization.
- Proactively and collaboratively interface with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care. Resolve member, family/caregiver assistance requests.
- Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home Health agency services. Performs retrospective reviews as needed for services rendered without an authorization.
- Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care. Coordinates with specialty vendors or providers for post-acute care needs.
- Contribute to the development and maintenance of policies and procedures to ensure regulatory compliance, identifying new policies and procedures that are required. Complies with all standards pertaining to accreditation (NCQA or other regulatory bodies).
- Demonstrate a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to effectively identify opportunities and coordinate referrals for care management intervention.
- Perform all required documentation and entry into utilization management operating system for authorization and determination.
- Contribute to the effectiveness and efficiency of the department. Participate in the documentation of the utilization management program, work plan, and annual evaluation including necessary submission to accreditation or other regulatory bodies.
- Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member satisfaction.
- Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards.
- Consistently adhere to department productivity and performance expectations.
- Consistently demonstrates an attitude of customer service excellence to both internal and external customers.
- Benefits Eligible: Yes
- Shift Details: Full-time Exempt, 40 hours per week. Hours are generally Monday through Friday business hours.
- Department: SelectHealth - Murray, Utah.
- Additional Details: This position is on our Medicaid team.
- Bachelor's degree in Nursing from an accredited institution (degree will be verified).
- Current RN license in state of practice.
- 3 years clinical nursing experience.
- 1 year in Managed Care, Utilization Management, or Case Management.
- Basic computer skills including word processing and spread sheets.
- Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively.
- Ongoing need for employee to see and read information, assess member needs and view computer monitors.
- Frequent interactions with providers, members that require employee to verbally communicate as well as her and understand spoken information, needs and issues accurately.
- Current working knowledge of Medicare, Medicaid and Commercial insurance.
- Current working knowledge of utilization management and case management techniques.
- Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
- Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
All positions subject to close without notice. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
Working Hours 40
Primary Work Location SelectHealth
Job Type Full Time
Location US-UT-Murray, US-UT-Salt Lake City