SENIOR OUTPATIENT UTILIZATION REVIEW NURSE

Job Summary:

Under the direction and oversight of the Supervisor of Utilization Management, the Senior Outpatient Utilization Review Nurse is responsible and accountable for coordination of services for members of Vivant Health, LLC for outpatient services as delegated. The Senior Outpatient Utilization Review Nurse coordinates all systems/services needed for an organized, multidisciplinary, patient centered team approach, and cost-effective care for Managed Medi-Cal patients. The Senior Outpatient Utilization Review Nurse follows and manages the course of treatment for patients while coordinating care with physicians, nurses, case managers and other staff from outside and within Company to ensure quality care and safe outcomes.  The Senior Outpatient Utilization Review Nurse also incorporates disease management protocols, ensures continuity of care through utilization of resources and refers to the health plans when applicable.

Responsibilities:

• Responds to complex medical issues, ensures consistency in the benefit application, may lead cross functional teams, projects, initiatives, process improvement activities.
• Serves as a proctor to new hires and participates in the training and/or retraining of nurses. 
• Responsible for managing a continuum of care for patients discharged to outpatient services.
  • Partners with medical staff, utilizes scientific evidence for best practices, relevant data and compliance with the mission/philosophy, standards, goals and core values.  
• Proactively assesses all potential case management and CCS member cases identified from either external or internal sources and actively manages all high-risk, high-volume cases throughout the continuum of the member’s health care needs or until they reach a maintenance mode.
• Demonstrates a multidisciplinary approach in identifying problems, communication and negotiating with the member’s PCP, family members, caregivers, other members of the health care team, community resources and the Health Plans. 
• Researches and refers members to sources for alternative funding, community services and other services which may provide support to the patient and family.
• Tracks all CCS referrals for timely notification of decisions.  Assists Medical Director with CCS appeals as applicable.
• Coordinates care for CCS members between PCP, CCS providers and other physicians and providers as needed as applicable. 
• Identifies cases for possible peer reviewers to evaluate the appropriateness and necessity of care and or quality of care concerns.
• Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.
• Will be required to review Requests for Authorizations and approve and/or refer to Medical Director/Chief Medical Officer for review and denial/modification.
• Applies managed care techniques to clinical practice within established criteria.
• Authorize outpatient services requested, determine medical necessity; specialty services, carve out services etc. 
• Process provider disputes, retro-requests, and reconsiderations, as applicable. 
• May also refer to social worker, complex case management, or other carve out services as needed.
• Completes appropriate, accurate and timely documentation into the Vivant Health system. 
• Reports quality of care issues to the Director of UM or Medical Director/Chief medical Officer.
• Provides ongoing evaluations of UM nursing activities according to the standards established by the Company, as well as the physicians and hospitals.
• Assists in preparing UM/QI case issues, gathering requested records/responses.
• Compliant with all departmental metrics: turnaround time, quality audits and productivity standards. 
• Possess knowledge of applicable regulatory standards 
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.

Competencies

• Four (4) years professional nursing experience in an acute care setting or outpatient setting preferred.
• Four (4) years utilization/case management experience in the managed care industry preferred.
• Medicaid Experience preferred.
• Strong oral and written communication skills, with the ability to communicate professionally with diverse individuals and groups inside and outside of Vivant.
• Excellent active listening and critical thinking skills.
• Strong analytical skills.
• Ability to solve mid-level problems with minimal supervision.
• Has the ability to be a leader for the department, shows leadership skills and initiative. 
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers/members.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrated excellence in project management and organization.
• Builds partnerships and works collaboratively with others to meet shared objectives. 
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment. 
• Demonstrate commitment to the organization’s mission.
• Ability to present self in a professional manner and represent the Company image. 

Education and Licensure

• High School Diploma or GED minimum requirement.
• Certificate or Diploma from an accredited school of nursing required.
• Active and Unrestricted Licensed Vocational Nurse CA License required.
• Active and Unrestricted RN License Preferred.
• Active and unrestricted Driver’s License.
• Current Auto Insurance.

Travel

• The incumbent may travel up to 75% of the time.

Work Environment

This job operates in a professional office environment.  This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.