Utilization Review Nurse

You, as the Nurse Reviewer will be held responsible for the comprehensive review of the medical information for the assigned medical record review and completion of all paperwork, communication and data entry involved. Reviews will include quality of care, medical necessity; DRG validation, focused, readmission, Emergency Medical Treatment and Active Labor Act [EMTALA], and all others are required by contract. Communicates with the Medicare beneficiary/family members, healthcare providers and/or practitioners as needed during the course of the identified review.

Essential Duties:

• Maintains current knowledge of the QIO contract, QIO Manual, SDPS Memorandums and Healthcare Communities Website to locate and apply up to date rules and protocols

• Recognizes barriers to completing work and uses clinical judgment to determine when to seek assistance from the Review Supervisor

• Communicates with the providers/practitioners via mail or phone regarding the need for clarification of requests and information provided in the correspondence letters.

• Responds in a timely manner to the providers and/or practitioners if there is a request for information or assistance in order to facilitate the completion of the assigned medical record reviews.

• Applies knowledge and expertise, analytical skills, critical thinking and business acumen to best meet customer needs.

• Communicates with Medicare beneficiary via mail or phone as needed

• Responds in a timely manner to the beneficiary if there is a request for information

• Frequently seeks and accepts feedback with regards to the review process; listens actively; maintains frequent and open communication.

• Collaborates to accomplish common goals to include accurate medical assessment of the beneficiary complaint and accurate Quality of Care Reviews.

• Recommend actions that may increase quality /productivity related to the review process.

• Communicates the current status of workload and availability for additional assignments

• Collaborates with the KEPRO team to identify additional process improvements that support enhanced beneficiary satisfaction and overall improvement of heal care.

• Collaborates with the KEPRO staff to support all contract requirements and identify additional contract improvements.