Review Nurse RN

Victorville, CA

Responsibilities:

• Coordinates and reviews all medical records, as assigned to caseload.
• Actively participates in Case Management and Treatment Team meetings.
• Serves as ongoing educator to all departments.
• Responsible for reviewing patient charts to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to requests for records from fiscal intermediary; gathering clinical and fiscal information and communicating the status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting.
• Able to work independently and use sound judgment.
• Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
• Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
• Responsible for providing timely and accurate referral determination.
• Identification of referrals to the medical director for review.
• Appropriate letter language and coding (denials, deferrals, modifications).
• Appropriate selection of the preferred and contracted providers.
• Proper identification of eligibility and health plan benefits.
• Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out.
• Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g., case management, engagement team, and disease management).
• Maintains and keeps in total confidence all files, documents, and records that pertain to business operations.
• Performs other duties as assigned.

EDUCATION & EXPERIENCE REQUIREMENTS:

• CA LVN license required. CA RN license preferred.
• Bachelor’s or Master’s degree in Social Work, behavioral or mental health, nursing, or other related health field preferred.
• 3 to 5 years of acute care experience preferred.
• Two (2) years managed care experience in UM/CM Department preferred.

SKILLS & ABILITIES REQUIREMENTS:

• Knowledge of CMS, State Regulations, URAC, and NCQA guidelines preferred.
• ICD-9 and CPT coding experience a plus.
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel, and experience working in a health plan medical management documentation system a plus.
• Experience in EZ-CAP preferred.
• Medical Terminology preferred.