Nurse, Concurrent Review

MAJOR RESPONSIBILITIES

•  Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including:

•  Admission reviews

•  Continued stay reviews

•  Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)

•  Related follow-up activities and documentation updates

•  Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions

•  Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions

•  Facilitates resolution of escalated cases that may require special handling

•  Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines

•  Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes

•  Maintains written documentation according to HealthHelp’s documentation policy

•  Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations

•  Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs

•  Complies with URAC & NCQA standards or other requisite regulating bodies

•  Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management

•  Keeps current with regulation changes as provided by Compliance Department and Nursing Management

•  Functions as subject matter expert to support Compliance Department initiatives and updates

•  Collects and enters confidential information ensuring the highest level of confidentiality in all areas

•  Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times

•  Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes

•  Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines

•  Appropriately identifies and refers quality issues to UM Leadership

•  Collaborates with client personnel to resolve customer concerns

•  Provides quality customer service through interaction with providers, administrative staff, and others

•  Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others

•  Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy

•  Participates in the HealthHelp Quality Management Program, as required

•  Performs other related duties and projects as assigned to meet business needs

SCHEDULE

7AM – 5PM PST/9AM – 7PM CST Monday- Friday while you should remain flexible based on business needs which could include weekends or alternative daytime hours.

Function: Other
Experience Level: Entry Level