Job Summary
Responsible for carrying out precertification and medical necessity reviews on all designated referrals as well as targeted outpatient procedures, services and inpatient admissions. The activities will include telephonic review for medical necessity of the RN designated targeted outpatient procedures, services and inpatient admissions, as well as referrals, utilizing established criteria and guidelines, retrospective ED reviews. In addition, they will perform eligibility and benefit reviews as necessary, identification of patients for case management, quality improvement reviews, and communicate with inpatient care coordinators, case managers, the SNF/Rehab care coordinator, members, providers, Customer Service, Claims, Contracts and Benefits - Appeals, Risk Management.
Essential Responsibilities
- Responsible for the day to day precertification and review activities as outlined above. Utilizes established criteria to perform precertification and referral review for all members requiring a procedure or service or with an admission diagnosis on the targeted review list for the RN. All referrals and precertification reviews will be performed within the required timeframe and the provider and member notified of the results. Refers all cases that do not meet established criteria to the appropriate review physician. Performs questionable benefit and eligibility reviews. Provides investigation and preparation of cases requiring review of the Chief of QRM: Non Contracted Providers Question of internal referral versus external referral or non-contract consultant performing services that can be provided internally. Any referral questionable for benefit Breast Reduction/Augmentation Varicose Veins Possible experimental/investigational procedures or treatments TMJ diagnoses. Referrals that are not approved due to not meeting medical appropriateness criteria. Understands the Complex Case Management Program and admission criteria and refers patients to the Complex Case Managers as appropriate. Provide correspondence, written and verbal, in accordance to policy and procedure for members with respect to referrals. Provides review of pended bills for specific types of referral cases.Interacts with physicians to ensure that resources are being utilized appropriately while maintaining quality outcomes. Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed. Refers the patient to the home care review team and/or social workers as appropriate. Ensures that the appropriate level of care is being delivered in the most appropriate setting based on established criteria and guidelines. Performs quality of care and service reviews using identified quality indicators. Coordinates and assists the Specialty Care Review Service$ Supervisor with ongoing physician education.
- Reviews the monthly analysis of statistics (cost/benefit) with the Specialty Care Review Services Supervisor and makes adjustments based on findings. Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management. Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, the SNF rounder, home care review team, social workers, inpatient care coordinators, referral coordinators, Member Services, Claims, Contracts and Benefits-Appeals, Risk Management and Kaiser Permanents medical offices to facilitate the precertification and referral process. Builds effective working relationships with physicians and other departments within the health plan. Assists in the development and revision of guidelines, pathways and protocols. Attends QRM Hospital UM meetings as requested. Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Review Services Supervisor. Under the guidance of the Review Services Supervisor and in consultation with other QRM staff, participates in the coordination, planning, development, implementation, and maintenance of all QRM policies and procedures related to the Specialty Care Review Program. Monitors utilization trends in the market area, keeping appropriate management informed. Initiates recommendations to facilitate reductions in utilization where appropriate. Refers cases identified as risk management, peer review or quality issues to QAIR and Risk Management.
- Document Review Activities to include: Medical necessity for admission/procedure. Diagnoses. Procedures performed. Demographic Data. Physicians involved in care. Other. Issue letters of non - coverage to members not meeting established medical necessity criteria. Works cross-functionally with other departments in striving to meet organizational goals and objectives. Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management. Knowledgeable and compliant with regional personnel policies and procedures. Knowledgeable and compliant with QRM departmental and unit specific policies and procedures. Participates in annual regional and departmental compliance training. Knowledgeable and compliant with Principles of Responsibility. Develops and maintains an awareness of how to report compliance issues and concerns. Other duties as assigned.
Basic Qualifications
Experience
- Minimum three (3) years of RN clinical nursing.
Education
- High school diploma or GED required.
License, Certification, Registration
- Registered Professional Nurse License (Georgia) required at hire
Additional Requirements
- Working knowledge of all relevant federal, state, local and regulatory requirements including Medicare.
- Functional knowledge of computers.
- Experience with Managed Health Care Delivery Systems.
- Experience in ICD9/CPT4 coding.
Preferred Qualifications
- Minimum three (3) years of clinical nursing; experience in ICU or medical/ surgical nursing care preferred.
- Minimum two (2) years of experience in utilization or case management, discharge planning and quality improvement in a health care or managed care setting preferred.
- Bachelors degree (B.S.) in nursing.