Currently seeking a part-time to full-time Nurse to act as a utilization review quality assurance supervisor. The position will be responsible for:
1. Providing Quality Assurance of the independent medical reviews.
2. Performing Utilization Management services within established clinical, productivity, phone and URAC standards.
3. Applying clinical skills and expertise in conjunction with established medical criteria to ensure independent reviews are accurate and complete.
4. Serve as subject matter expert on complex medical management issues.
5. Performing other related projects and duties as assigned.
1. Responsible for assessing and monitoring services for inpatient, outpatient, home health care and skilled nursing facilities utilizing thorough knowledge of multiple criteria sets and products.
2. Responsible for maintaining knowledge of community resources and health plan programs.
3. Responsible for preparing documentation to provide the utmost quality of reviews.
4. Responsible for facilitating consistent, sound and defensible medical decisions, according to established coverage guidelines/policies, national industry-standard care guidelines, and current scientific evidence as it applies to each case
5. Efficiently and accurately communicate necessary changes for the non-medical staff following established timelines.
6. Evaluate and analyze available literature on new and existing technologies to determine safety and effectiveness as it relates to the quality of independent reviews.
7. Ability to abstract pertinent clinical findings and appropriately apply to corresponding clinical criteria.
8. Maintain confidentiality of case information.
9. Other duties as assigned
1. Currently licensed Registered Nurse preferably B.S.N.
2. Five years of experience as an RN in medical/surgical, critical care, home care, or equivalent knowledge of current hospital and clinical care processes
3. Experience in utilization review, utilization management, quality review or discharge planning
4. Excellent verbal and written communication and interpersonal skills
5. Excellent problem identification/problem solving and follow through skills
6. Ability to organize and prioritize multiple assignments within workload
7. Ability to function independently and take independent action, within the scope of job responsibilities.
1. Experience in managed care environment
2. Experience in working with established criteria to determine medical necessity and appropriateness of care
3. Demonstrated knowledge and familiarity in research methodologies and ability to interpret medical literature.
4. Computer experience with word processing, spreadsheets, data base management
5. Bachelor of Science in Nursing
Apply at www.admere.com.