Role Description
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Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including:
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Admission reviews
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Continued stay reviews
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Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)
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Related follow-up activities and documentation updates
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Engages in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions.
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Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions.
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Facilitates resolution of escalated cases that may require special handling.
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Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines.
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Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
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Maintains written documentation according to HealthHelp’s documentation policy.
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Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations.
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Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
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Complies with URAC & NCQA standards or other requisite regulating bodies.
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Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
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Keeps current with regulation changes as provided by Compliance Department and Nursing Management.
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Functions as subject matter expert to support Compliance Department initiatives and updates.
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Collects and enters confidential information ensuring the highest level of confidentiality in all areas.
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Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times.
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Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes.
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Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines.
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Appropriately identifies and refers quality issues to UM Leadership.
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Collaborates with client personnel to resolve customer concerns.
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Provides quality customer service through interaction with providers, administrative staff, and others.
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Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others.
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Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
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Participates in the HealthHelp Quality Management Program, as required.
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Performs other related duties and projects as assigned to meet business needs.
Qualifications
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RN graduate from an accredited school of nursing (BSN preferred).
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Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent).
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Two (2) years of experience in an acute care setting, required.
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Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred.
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Experience with InterQual or similar evidence-based clinical decision support criteria, preferred.
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Willingness to complete and maintain InterQual certification and ongoing competency requirements.
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Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred.
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Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements.
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Knowledge of insurance terminology.
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Experience working with state and federal regulatory and compliance standards, preferred.
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Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required.
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Good organizational and time management skills.
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Excellent written and verbal communication skills.
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Ability to utilize critical thinking skills.
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Highly motivated, self-starter who can work efficiently and independently, or as a team member.
Benefits
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Medical, dental, and vision insurance.
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Paid time off (PTO), holidays, and sick leave.
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401(k) with company match or other retirement plan.
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Life and AD&D Insurance.
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Employee Assistance Program.
