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The Utilization Management Nurse (UM) is responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Utilization Management Nurse works under the direct supervision of an RN or MD.
Please note: This is an office based position located at our office off of Northwest Parkway in San Antonio, TX. The position requires a rotating Saturday shift.
- Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
- Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
- Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
- Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
- Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times.
- Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
- May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
- Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
- Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
- Documents rate negotiation accurately for proper claims adjudication.
- Identify and refer potential cases to Disease Management and Case Management.
- Performs all other related duties as assigned.