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Nurse Case Management Lead Analyst
Ref No.: 20-05113
Location: Houston, Texas
Title: Inpatient Review Nurse
Location: Houston, TX
Contract: 11/02/2020 - 1/31/2021 (extension/conversion potential)
Hours: Monday - Friday, 8am - 5pm OR Thursday - Sunday 9am - 7pm

Primary Function:

Under the supervision of the Health Services Management Supervisor and Manager of Inpatient Utilization Management, the Inpatient Review Nurse is responsible for effective, efficient medical management of the population. The Inpatient Review Nurse is responsible for the effective, efficient & proactive completion of all utilization management activities that facilitate the member's movement through the continuum of care. Responsibilities include prospective, concurrent & retrospective reviews of Inpatient, LTAC, SNF & Rehabilitation members in their area of assignment. Medical necessity determinations and appropriateness of setting will be determined based on established policies and approved criteria.

  • Performs all utilization review activities according to Health Services policy and procedures.
  • Conducts onsite/telephonic review as assigned to obtain required information.
  • Evaluates and authorizes the medical necessity of inpatient and observation services as assigned by application of approved criteria and established policies and guidelines.
  • Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines.
  • Facilitates the movement of the member through the continuum of care in a proactive manner.
  • Refers cases to the Medical Director/POD Medical Director as appropriate.
  • Concurrently enters all information into the healthplan's computer documentation system ensuring complete and accurate information per established policies and guidelines.
  • Completes opportunity report concurrently and any other reports or request for information in a timely manner.
  • Notifies hospital and/or providers of all denials and generates the denial letters template to forward to the Denial team as directed by the Medical Director within assigned time frames.
  • Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator
  • Reviews selected retrospective requests for certification and follow-up as necessary with Health Services Supervisor, Manager of Inpatient Utilization or Medical Director.
  • Participates in education of providers regarding Health Services policies and procedures.
  • Identifies and refers cases concurrently to CM or Rapid Response unit as appropriate and indicated in established policies and guidelines.
  • Performs member/family interviews and assists in discharge plan development and coordination of care.
Job Related Skills:
  • Excellent verbal and written communication skills. Written and oral communication is accurate and timely and at the appropriate level.
  • Ability to articulate clinical and non-clinical information to personnel/members at all levels of understanding.
  • Ability to communicate with all team members in a positive & professional manner.
  • Excellent organizational skills and time management skills. Ability to multi task and prioritize.
  • Assists in the education of internal and external staff in operations, policies and procedures, and regulatory standards.
  • Demonstrates critical thinking and problem solving skills.
  • Knowledge of health insurance industry and processes.
  • Detail oriented, highly self-motivated, responsive and dependable.
  • Team and goal oriented.
  • Basic knowledge of mainframe/PC systems and keyboarding skills.
  • Bilingual (conversational and written ) preferred
Position Qualifications/Requirements:
  • Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor's Degree Program.
  • 2-3 years clinical experience with at least 1-2 years in utilization review. Managed Care experience preferred.
  • Knowledge of ICD-10 coding, CPT coding and Interqual guidelines for utilization review.
  • Current and valid Texas Registered Nursing License required.
  • Current Driver's license with current auto insurance.