Utilization Nurse - MLTC

Posted on Mar 10, 2019 by Extended MLTC, CHHA & At Home

Staten Island, NY 10301
Health Care
Immediate Start
Annual Salary
Full-Time
Location: Staten Island, New York, , United States
Job ID:
Posted: 03/08/2019
Position Title: Utilization Nurse - MLTC
Company Name: Extended MLTC, CHHA & At Home
Sector: Home Health Care Provider
Entry Level: false

Overview
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.

Responsibilities

  • 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.


Qualifications

  • 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

Reference: 667262570

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