Concurrent Review Nurse (Signing Bonus)
Concurrent Review Nurse
Under the general supervision of the Director of Health Services, the position is responsible for ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient precertification and prior authorization of services by utilizing applicable medical policy, evidenced based industry standards and managed care products.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Develops, educates, and manages clinical and non-clinical staff within the guidelines of Leon
- Health’s policies and procedures to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently.
- Responsible for monitoring incoming calls and written inquiries from members, providers, and inhouse departments.
- Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization reviews
- Responsible for the data entry of service requests/decisions into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies.
- Reviews clinical documentation for pre-certifications and continued (concurrent) reviews prior tothe review.
- Conducts on site and/or telephonic reviews for appropriateness of treatment setting on inpatient/outpatient admissions and continued (concurrent) stays utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
- Conducts Medical and BH reviews prior and post authorization service requests utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
- Provides authorization to providers, facilities, and members (when applicable) for inpatient admission, outpatient precertification, prior authorization, and post service requests.
- Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate.
- Provides complete and accurate documentation specifying rational for approvals.
- Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.
- Updates census reports, notes, and all authorization documentation daily including running a daily admissions and discharge report.
- Collaborate with clinicians and/or providers to obtain necessary clinical documentation for medical necessity reviews.
- Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
- Facilitates member care transition through the healthcare continuum by collaborating with facilities and Care Management.
- Monitors and evaluates the quality, timeliness, and accuracy of prior authorization reviews.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Assists in peer training as needed.
- Participates in Quality Improvement and Risk Management activities as requesteParticipates in training and in-service education as required.
- Participates in department, clinic and other meetings as requested.
- Complies with the organizaion’s policies and procedures and maintains confidentiality in accordance with state and federal laws.
- Participates in special projects and performs other duties as assigned.
Rotating on call-weekends.
- Minimum of two (2) years of experience in clinical reviews
- Problem solving proficiency; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
- Process/systems skills with the ability to work with data for data-driven decision making and process improvements
- Medicare and/or Medicaid managed care experience
- Knowledge of Dual Eligible Special Needs Plans, Centers for Medicare and Medicaid Services (CMS), and Florida Medicaid
- Understanding of medical necessity for appropriate member status and level of care
- Strong verbal and electronic communication skills
- Supports positive employee relations and customer experience
- Understanding of Microsoft Office Products and other appropriate software platforms
- Ability to work autonomously with self-direction
- Proficient problem solving approach to quickly assess current state and formulate recommendations
- Proficient in translating healthcare-related jargon and complex processes into simple, step-bystep instructions customers can understand and act upon
- Flexibility to customize approach to meet all types of member communication styles and Personalities
- Ability to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 8:00pm EST
Bachelor degree in Nursing
Bilingual English/Spanish fluency.
CERTIFICATES, LICENSES, REGISTRATIONS
PHYSICAL DEMANDS/WORK ENVIRONMENT
Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays. Position requires the ability to work extended hours when necessary.