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Nurse Reviewer - Facility Utilization Review
Exempt or Non-ExemptExempt
Under minimal supervision, conducts detailed analysis and review of inpatient hospital stays and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally-accepted clinical guidelines to determine appropriateness of care for all HMSA members.
- Associates Degree in Nursing
- Current, unrestricted Nursing License in the state of Hawaii as an RN.
- Two years clinical care experience or case management or related experience.
- Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
- Good working knowledge of Microsoft Office applications including: Outlook, Word, and Excel.
- Good typing skills
- Strong organizational skills
- Good communication skills both verbally and written
- Multi-tasking skills
- Critical thinking skills
Duties and Responsibilities
- Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes determination of inpatient hospital stays as medically appropriate for the member's clinical condition or whether the stay requires referral to a Medical Director for potential denial. The Nurse Reviewer must follow each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admission. Responsibilities include using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
- Promote improved quality of care and/or life
- Promote cost effective medical outcomes
- Prevent hospitalization when possible and appropriate
- Promote decreased lengths of hospital stays when appropriate
- Ensure the quality of care member is receiving during hospital stay is appropriate
- Ensure appropriate levels of care are received by patients
- Consult with Medical Directors on potential quality issues encountered during review of medical records in situations when the complexity of the member's medical, surgical and/or pharmaceutical management is unclear and may require further review or intervention and follow up with attending physicians, hospitalists or other facility staff