JOB SUMMARY

Responsible for reviewing prior authorization requests for medical services including elective admissions (Post-Acute and Acute), inpatient surgeries, outpatient surgeries, home health, and durable medical equipment. RN will prioritize expedited requests for medical necessity and efficiency in accordance with health plan coverage guidelines and CMS coverage determinations. Demonstrates proficiency in the application of national and local clinical case review criteria for precertification requests.  Ensures compliance with all delegated and regulatory requirements. The nurse works under the direction of and collaboratively with the UM Team Lead and physician reviewers for questionable medical necessity codes and issuance of denials including Integrated Denial Notice (IDN), Notice of Medicare Non-Coverage (NOMNC), Detail-Explanation of Non-Coverage (DENC), and follow the Health Plan appeal process & Quality Improvement Organization (QIO) process. The nurse ensures the appropriate application of HTA’s PAL (prior authorization list), CMS NCD’s and LCD’s, Health Plan criteria, and HTA’s Evidence of Coverage on all authorization requests.    

ESSENTIAL DUTIES AND RESPONSIBILITIES

This position must be able to:

Utilization Management Adjudication

• Supports the Collaborative Utilization Management Model as a working partner with physicians, social workers, pharmacists, and other professional staff.  Demonstrates proficiency in the application of national and local clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events.
• Demonstrates a solid understanding of managed care trends, Medicare & Medicaid regulations, reimbursement, and the effect on utilization and outcomes of the different methods of reimbursement.
• Establishes priorities during routine daily operations, addressing time-sensitive reviews/matters first, while also accomplishing day-to-day tasks and duties. Effectively triages tasks and events according to urgency level, impact on patients, and outcomes desired under special conditions (e.g., during crises and emergencies). Makes choices that result in maximum completion of essential duties and minimum personal stress.

Regulatory Compliance

• Ensures complete and accurate documentation in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
• Identifies and refers cases to the Physician for Medical Review when services do not meet medical necessity criteria and/or appropriate level of care.
• Ensures compliance with regulatory turnaround times & HIPAA (Health Insurance Portability and Accountability Act).

Customer Service

• Works collaboratively with requesting providers to ensure quality and appropriateness of care is being provided to members.  Aids in post-inpatient discharge review when requested. Provides guidance and assistance with complex care cases to identify barriers, develop action plans, and program modifications for change.
• Demonstrates the ability to develop departmental relationships with internal and external customers to provide exemplary service and achieve goals.
• Demonstrates participation in multi-disciplinary team rounds to address utilization/resources and progression of care issues, and assist in developing and implementing an improvement plan to address issues.
• Perform other duties as assigned

EDUCATION AND EXPERIENCE 

Education:

• RN or BSN
• Current NC RN licensure in good standing
• Annual Flu Vaccine

Required Experience:

• 2 years of utilization management experience with an acute and/or post-acute provider or health plan and/or other care company experience
• 2 years of medical/surgical experience
• Working knowledge of computers and basic software applications used in job functions such as typing/word processing, databases, spreadsheets, etc.

Preferred Experience:

• RN, BSN with work experience in Business or Health related field
• Health Plan UM experience
• 3 years of experience in Utilization Review, Discharge Planning, and Medical Case
• Management in a hospital or post-acute care setting
• Home Health and/or DME experience is highly desirable
• Strong analytical and organizational skills
• Working knowledge and ability to apply professional standards of practice in a work environment.
• Knowledge of national and local coverage determinations and managed care requirements.

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
• Exerting up to 20 pounds of force occasionally (up to 1/3 of the time), and/or;
• up to 10 pounds of force frequently (1/3 to 2/3 of the time), and/or:
• a negligible amount of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible
• Exerting 20 to 50 pounds of force occasionally (up to 1/3 of the time), and/or;
• 10 to 25 pounds of force frequently (1/3 to 2/3 of the time), and/or Greater than negligible up to 10 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting 50 to 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• 25 to 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• 10 to 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting in excess of 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• in excess of 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• in excess of 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.

Benefits from Day One: 

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.

ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in multiple North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.