Concurrent Review (RN)

SUMMARY

Under the general supervision of the Director of Health Services, the position is responsible for ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient precertification and prior authorization of services by utilizing applicable medical policy, evidenced based industry standards and managed care products.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

• Develops, educates, and manages clinical and non-clinical staff within the guidelines of Leon Health’s policies and procedures to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently.
• Responsible for monitoring incoming calls and written inquiries from members, providers, and in-house departments.
• Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization reviews.
• Responsible for the data entry of service requests/decisions into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies.
• Reviews clinical documentation for pre-certifications and continued (concurrent) reviews prior to the review.
• Conducts on site and/or telephonic reviews for appropriateness of treatment setting on inpatient/outpatient admissions and continued (concurrent) stays utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
• Conducts Medical and BH reviews prior and post authorization service requests utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
• Provides authorization to providers, facilities, and members (when applicable) for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate.
• Provides complete and accurate documentation specifying rational for approvals.
• Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.
• Updates census reports, notes, and all authorization documentation daily including running a daily admissions and discharge report.
• Collaborate with clinicians and/or providers to obtain necessary clinical documentation for medical necessity reviews.
• Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum by collaborating with facilities and Care Management.

• Monitors and evaluates the quality, timeliness, and accuracy of prior authorization reviews.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Assists in peer training as needed.
• Participates in Quality Improvement and Risk Management activities as requested.
• Participates in training and in-service education as required.
• Complies with Leon Health’s policies and procedures and maintains confidentiality of patient’s medical records in accordance with state and federal laws.
• Maintains open channels of communication with other company departments.
• Answers all inquiries in a professional and courteous manner.
• Performs other duties as assigned.
• Rotating on call-weekends.

KNOWLEDGE AND SKILLS REQUIRED:

• Knowledge of Dual Eligible Special Needs Plans, Centers for Medicare and Medicaid Services (CMS), and Florida Medicaid
• Understanding of medical necessity for appropriate member status and level of care
• Strong verbal and electronic communication skills
• Supports positive employee relations and customer experience
• Understanding of Microsoft Office Products and other appropriate software platforms
• Ability to work autonomously with self-direction

EDUCATION AND EXPERIENCE REQUIRED:

• Registered Nurse
• 2-5 years of experience in clinical reviews
• Problem solving proficiency; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
• Process/systems skills with the ability to work with data for data-driven decision making and process improvements
• Medicare and/or Medicaid managed care experience
• Bilingual (English/Spanish)

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

• State of Florida RN license