Temporary Utilization Review Nurse

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond.  As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community.  Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day.  Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
 

Position Summary
 

The Utilization Review Nurse works as a member of a team responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations.
This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, receives and reviews notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes.
The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
-Ensure members are receiving appropriate level of care
-Promote cost effective medical outcomes
-Prevent hospitalization/ readmissions when appropriate
-Promote decreased lengths of hospital stays when appropriate
-Provide for continuity of care

Job Description

Key Outcomes/Results:

• Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.

• Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.

• Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues

• Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to: authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.

• Coordinates referrals to Care Management, as appropriate.

• Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable.  Maintains knowledge of applicable regulatory guidelines.

• Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.

• Participates as a member of an interdisciplinary team in the Health Management Department

• May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team

• Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time

• Mentors new staff into case management role as assigned.

• Assumes extra duties as assigned based on business needs.

• Participates on com