UM Outpatient Clinical Review Nurse

Job Description

Job Description

Purpose

Contributes to the overall success of the Utilization Management department by performing clinical reviews for outpatient, including determining the member’s overall health, reviewing the type of care being delivered, and evaluating medical necessity, in compliance with governing regulations, internal policies, and procedures.

Accountabilities

• Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge.
• Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
• Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.

• Champions a high performance environment and contributes to an inclusive work environment.

Essential Job Functions

• Performs pre-service, concurrent, and retrospective reviews of members for appropriate care and setting to determine overall health and appropriate level of care, using applicable coverage documents and clinical guidelines
• Collects, documents, and maintains review findings and actions taken on member medical records in health management systems, according to utilization management policies and guidelines
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested service and review findings
• Collaborates with Medical Directors, when determination to deny a request is indicated
• Assists with providing education to providers on utilization processes to ensure high quality, appropriate care to members
• Collaborates with care management on referral of members, as appropriate
• Performs clinical reviews for member and provider appeals related to outpatient services
• Participates in the weekend call program, as well as flexible work hours, as needed within the department
• Provides input to the Medical Policy Committee regarding the development/updating of medical policies
• Orients new staff to role, as needed
• Complies with all policies and standards
• Models professionalism and leadership in all capacities of the position to all audiences
• Performs other duties as assigned

Position: UM Outpatient Clinical Review Nurse /Utilization Management

Reporting Relationships (Job Titles only)Primary Manager:

(include secondary Manager if applicable)

• Manager of Utilization Management

Direct Reports:

• N/A

Shared Reports (solid/dotted if applicable):

• N/A

External/Internal Contacts

Internal

• Utilization Management

External

• Health New England Members and Providers

Education / Experience / Other Information (include only those that are specific to the role)

Bachelor’s degree in nursing preferred with 3-5 years’ experience of outpatient care, or equivalent combination of education and experience.

• Current Massachusetts Registered Nurse license required
• Knowledge of utilization management processes preferred
• Knowledge of Medicare and Medicaid regulations preferred
• Highly developed critical thinking skills
• Computer literacy and ability to navigate through computer systems
• Excellent written and verbal communication skills, including delivering presentations
• Excellent time management skills with the ability to manage multiple priorities
• Ability to manage an assigned caseload independently
• Strong teamwork skills

Working Conditions

Standard office environment, with extended period of time sitting, looking at monitors, typing on laptops and

communicating via softphones/headsets for virtual meetings. No traveling required.