Job Description

Utilization Review Nurse

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to ensure members receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.

Job Description

Key Outcomes:

• Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
• Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
• Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues
• Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources.
• Coordinates referrals to Care Management, as appropriate.
• Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations.
• Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
• Participates as a member of an interdisciplinary team in the Health Management Department.
• May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team.
• Establishes and maintains strong professional relationships with community providers.
• Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time.
• Mentors new staff as assigned.
• Maintains quality audit scores within department standards.
• Maintains productivity within department standards.
• Assists in creation and updating of department policies and procedures.
• Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
• Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
• Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
• Assumes extra duties as assigned based on business needs, including weekend rotations

Education/Experience:

• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
• Utilization management experience in a health plan UM department

Required License(s) and/or Certification(s):

• Compact RN License
• Certification in managed care nursing or care management desired (CMCN or CCM)

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin's Point Values.
• Maintains current licensure and practices within scope of license for current state of residence.
• Maintains knowledge of Scope of Nursing Practice in states where licensed.
• Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately.
• Ability to analyze data metrics, outcomes, and trends.
• Excellent interpersonal, verbal, and written communication skills.
• Critical thinking: can identify root causes and understands coordination of medical and clinical information.
• Ability to prioritize time and tasks efficiently and effectively.
• Ability to manage multiple demands.
• Ability to function independently.
• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer.

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