What are the responsibilities and job description for the Utilization Review Nurse position at Med National Staffing Inc.?
Job Description:
All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members.
Must Have Skills:
Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelines. Bi-lingual in any language is preferred but not mandatory
REQUIRED:
Experience with actually reviewing for Medicaid/ MLTC members not Medicare or IP reviews as those are very different with a different workflow and process. Candidates must be aware that this is a fast-paced environment with a Turnaround Timeframe of 3 business days on average for our std requests 72 hours urgent/expedited requests.
Day to Day Responsibilities:
All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews, meeting expected productivity and performance Productivity expectations are set a by Clinical Services based on the local HP time studied performance. Standard full capacity and performance reviews expectations is 30 cases a day – there will be a 6-8 week ramp up period to full capacity post successful completion of New hire and HP specific training.
Required Years of Experience:
At least 1-2 years’ experience in UM.
Required Licensure / Education: Licensure required is a NY State License Practical Nurse or Registered Nurse -LPN NY & NY RN
Salary : $42