Ensures accurate and timely prior authorization of designated healthcare services.

Utilization Management Nurse:
Performs prospective, first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as FEP.
Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
Clinical judgment and detailed knowledge of benefit plans used to complete review decisions.
Essential Responsibilities:
*Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
*Ensures diagnosis matches ICD10 codes.
*Solicits support from SME's, leads and managers as appropriate.
*Participates in huddles/ team meetings.  
*Triages and prioritizes cases to meet required turn-around times.
*Expedites access to appropriate care for members with urgent needs.
*Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determination.
*Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
*Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
*Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
*Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.
*Identifies potential over-payments: - CISD reviews claims for Medical Necessity for Providers - FCR reviews claim for Facility Compliance Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
*Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
*Other duties as assigned

Skills

General Knowledge & Experience Required:
*Current CA RN License.
*Bachelors of Science in Nursing or advanced degree preferred
*Requires practical knowledge of job area typically obtained through advanced education combined with experience.
*Typically, requires a college degree or equivalent experience and 3 years of prior relevant experience.
*Pre-Service Review Specific requirements:
*Knowledge of CPT-4, ICD-10, HCPCs, with minimum of 1 year of experience in coding.
*Knowledge of contract language.


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