UTILIZATION MANAGEMENT NURSE The UM Nurse is responsible for performing precertification, prior approvals, concurrent and retrospective reviews, and coordination of discharge planning. Tasks are performed within the scope of practice, under Medical Director direction, using independent clinical judgment and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery. Roles and Responsibilities: · Performs utilization review of outpatient procedures and ancillary services. · Determines medical necessity and appropriateness of services using clinical review criteria. · Accurately documents all review determinations and contacts providers and members according to established timeframes. · Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director. · Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director · Appropriately identifies potential cases for Care Management programs. · Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. · Performs accurate data entry. · Communicates appropriate information to other staff members as necessary/required. · Participates in continuing education initiatives. · Collaborates with Claims, Quality Management and Provider Relations Departments as requested. · Performs other duties as assigned. Qualifications: · An active and unrestricted Nursing License in the Philippines and in mainland US (PHRN and USRN) · At least one (1) year experience with Utilization Management Review particularly in a Managed Care environment · At least two (2) years of prior acute care experience in the ICU, CCU, ER, Neuro, ICU or Progressive Care Unit. · Knowledge of managed care principles, HMO and Risk Contracting arrangements · Preferred experience with clinical decision-making criteria sets (i.e. Milliman, InterQual) · Demonstrated ability in using computer and Windows PC applications, which includes strong keyboard and navigation skills · Must possess good written and oral communications skills, organizational skills; be proficient in decision making, problem solving, and time management. · Typing speed of >45 words per minute preferred. · Ability to multitask in a fast-paced environment · Proficient in MS Outlook, Word and Excel and general computer literacy, working with dual screens· · Ability to maintain strict confidentiality of protected health information · Willing to work any assigned shift during a week in Makati City All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, ethnicity, age, disability, marital status, or any other characteristic protected by law. Genfinity as an Equal Opportunity Employer, believes in each person's potential, and we'll help you achieve yours. All information will be kept confidential according to EEO guidelines. Powered by JazzHR
