Utilization Mgmt Nurse Reviewer
Company: Allegiance Benefit Plan Mgmt.
Posted on: January 13, 2019
POSITION RESPONSIBILITIES: This position is responsible for performing medical/surgical and psychiatric/CD reviews. This includes certification reviews, continued stay reviews, patient information and education, individual case management referral, and processing of appeals. This position may also include participating in team functions such as committees, QA team evaluations, and preceptorships. The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and be respectful and courteous in the conduct of this position. ESSENTIAL JOB FUNCTIONS: Essential job functions include the following. Other functions may be assigned as business conditions change. Able to effectively initiate and return telephone messages independently, as evidence by individual compliance with QA requirements. Able to initiate and complete certification review (pre-admission, admission, and concurrent review) independently, as evidenced by individual compliance with QA requirements. Able to initiate phone calls requesting information for admissions and continued stay reviews. Able to identify and refer cases NOT meeting established criteria to the Healthcare Advisor. Criteria includes but, is not limited to: American Society of Addiction Medicine (ASAM) Milliman and Robert (M&R) Provide accurate information to callers as evidenced by GEN entry/documentation. Compliance with protocols and QA requirements. Processing of appeals as evidenced by compliance with protocols. Able to function as training preceptor as evidenced by completion of trainee checklist. Successful completion of comprehensive case studies after six months as a Reviewer, and as performance dictates thereafter. Participates in team meetings, committees, or committee assignments as evidenced by: Completion of tasks assigned by team or committee. Completion of team QA evaluation in compliance with QA protocol; and Knowledge to present and participate in provider/subscriber and group services, workshops, and educational seminars. Performs other duties and job functions as assigned. NON-ESSENTIAL JOB FUNCTIONS: Preparation of forms, faxing, copying. Organizion of files and referance materials. Ability to operate typical office equiptment and working knowledge of basic office practices. PHYSICAL WORKING CONDITIONS: Physical requirements are representative of those that must be met to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Sitting 80% Reaching Minimal Standing 10% Manual Dexterity Ability to type/keyboard Walking 10% Telephone High Degree Kneeling As needed Computer Screen High Degree Bending As needed Lifting 25 pounds JOB SPECIFICATIONS: To perform this position 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 Education, Licensure, Certification: RN Licensure Minimum Experience: Two years experience in medical/surgical, rehabilitation, psychiatric, or emergency services, and/or certification review experience; comparable outpatient experience Other Experience: Must be able to access, research and extract information from printed resources, computer terminals, medical records, and telephone interviews on a daily basis. Must have strong organizational skills, the ability to follow directions, interpret instructions, and solve practical problems. Must have excellent communications skills (listening, verbal, written) and be customer service oriented. Must be able to function independently, effectively, and cooperatively with little supervision, meet assignment deadlines, work with a variety of tasks simultaneously, do detailed work accurately, and follow through to completion. The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified. By signing this statement, the employee understands the scope of their licensure and will practice within the scope of that licensure. If the status of the licensure/certification changes, the employee will notify the department supervisor of the change immediately. The employee understands that failure to maintain current licensure and/or to practice within the scope of that licensure, as well as failure to report any changes in license status, will result in disciplinary action, up to and including termination. Job Posted by ApplicantPro
Keywords: Allegiance Benefit Plan Mgmt., Boise , Utilization Mgmt Nurse Reviewer, Healthcare , Boise, Idaho
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