Utilization Nurse - MLTC
Posted on Mar 10, 2019 by Extended MLTC, CHHA & At Home
Position Title: Utilization Nurse - MLTC
Company Name: Extended MLTC, CHHA & At Home
Sector: Home Health Care Provider
Entry Level: false
The Utilization Nurse will be responsible for reviewing authorization requests/claims for medical necessity, under the direction and supervision of the Director of UM/Transitional Service Dept.
- Act as a liaison between the care manager and the provider
- Reports to Director of UM/Transitional Service Dept
- Utilizes the Utilization/Transitional Nurse Manager as a resource for all clinical questions and advice, in collaboration with Director of UM/Transitional Service Dept
- Serve as part of the team for treatment plans. Follows up with all necessary parties regarding treatment requests
- Reviews the appropriateness and medical necessity of the treatment requests for utilization review on a prospective, concurrent, and retrospective basis. Report their findings to Director of UM/Transitional Service Dept for determination
- Reviews and assists with coordination of the POC
- Reviews the quality and clinical risk issues on a concurrent basis; report any recognized issue to the Director of UM/Transitional Service Dept
- Reviews the documentation in the medical records for completeness and relationship to the treatment plan and reports findings to Director of UM/Transitional Service Dept
- Able to obtain and interpret information appropriate to the members needs as required for assessment, treatment, and patient care services, as delegated by the Director of UM/Transitional Service Dept
- Provide assistance and guidance to all parties with regard to the authorization request/claim process
- Assist with analysis of outcome data to identify and make recommendations; report issues to the Director of UM/Transitional Service Dept
- Develop and maintain a positive work atmosphere and support the overall team; demonstrate ability to work within a team structure
- Practice capable and effective problem identification and resolution skills as a method of sound decision making
- Maintain confidentiality
- Work independently, efficiently, and deals with priorities, under the direction and supervision of the Director of UM/Transitional Service Dept.
- Ability to function as a Utilization Nurse and any other duties as assigned
- Practice nursing within the Scope of Practice as designated
- Employee may be asked to travel from time to time to attend employer meetings or other offsite functions.
- Demonstrates sound judgment by taking appropriate actions regarding suspected violation of corporate compliance regulations.
- Reports all suspected violations to supervisor, Compliance Officer or Compliance Hotline.
- Licensed Professional Registered Nurse
- A minimum of five (5) years of full-time employment in home health care, utilization, and nursing.
- Excellent verbal/written communication skills, strong organizational skills, and good judgment
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