Utilization Review / Medical Review and Appeals RN
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.
Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
Identify and document quality of care issues; resolve or route to appropriate area for resolution.
Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
Other duties may be assigned based on designated department assignment.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
Working knowledge of current industry Microsoft Office Suite PC applications.
Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
Knowledge of cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources.
Knowledge of applicable accreditation standards, local, state and federal regulations.
Other related skills and/or abilities may be required to perform this job based upon designated department assignment.
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utilization review, case management, case manager, care coordinator, appeals, denials