Utilization Management RN Job at GMG Health Systems, LTD
UM Nurse focuses on the prospective UM review process at GMG, though also handles some concurrent and retrospective reviews. GMG providers and external providers seek approval of referral requests for future services. Reviews must be conducted according to defined process and timeline guidelines for expedited and standard l requests. The UM Nurse is called on to provide Clinical insight to help enhance decision making, and the review process. Helps to ensure UM delegation is being carried out correctly in GMG’s daily operations. And that completion of UM tasks is performed timely, and as efficiently / effectively as possible.
Duties:
- Carries out GMG UM Program activities and UM operations.
- Provides clinical perspective/input to Review team, UM team, Referral Specialists.
- Summarizes medical record documentation for physician medical necessity review.
- Composes Denial letters according to CMS defined standards and according to UM delegation rules.
- Applies evidenced-based criteria to medical necessity reviews and documentations appropriately in review summary.
- Performs daily authorization oversight to insure proper completion of referral documentation in EZ Cap and Centricity, timeliness of determinations and compliance with UM Delegation requirements in daily operations.
- Pulls, scrubs and submits ODAG reports, Part C reports and other UM reports to health plans upon request, meeting submission deadlines.
- Successfully performs live ODAG reviews with health plan auditors; successfully responds to “desk review” requests, by submitting screen prints and documents within defined timeline.
- Contributes to delegation audits and fulfilling certain requirements for UM delegation related to
- Making UM criteria available to requesting providers upon request
- Non-contracted providers are consistently identified appropriate State, OIG, MCR opt out screening are carried out prior to approving the referral service.
- Ensures use/documentation of Board Certified Specialists in making referral decisions.
- Other UM requirements for training, monitoring performance measures, etc.
- Ensures GMG UM team responds timely to inquiry from claims vendor where an authorization has NOT been obtained previously.
- Identifies opportunities for operational improvement, and works collaboratively with UM team, Provider PODS, and other GMG departments.
- Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers.
- Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed.
- Participates in preferred provider meetings to discuss Network status and Network Development needs.
- Promotes the Contracted Network Providers to GMG patients and staff.
- Promotes teamwork in daily activities. Exercises tact and courtesy when dealing with patients / families, Network staff, Providers and co-workers.
- Maintains strict confidentiality. Practical HIPAA knowledge and focus.
- Other duties as assigned.
Education and Experience: Minimum Associates Degree in Nursing required. Prefer BS in nursing or healthcare related field. Requires at least 2 years’ experience in Managed Care/ Utilization Management experience. Previous supervisory/management experience preferred. Must have knowledge of ICD-10 and CPT-4 coding, medical terminology. Must have strong verbal and written communication skills. Able to work efficiently under pressure.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet
Software. Able to operate common office equipment.
Supervisory Responsibilities: This job will not direct have supervisory responsibilities.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in
a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing
radiation, medicinal preparations, and other conditions common to a clinic environment.
Physical Demands: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching,
bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.
The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties as assigned by their Manager. Reasonable accommodations may be made to enable otherwise qualified individuals with disabilities to perform the essential functions of the job.
Education
Required- Associates or better in Nursing
Licenses & Certifications
Required- Registered Nurse
Behaviors
Preferred- Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
Motivations
Preferred- Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
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