TIHP UTILIZATION MANAGEMENT NURSE

Primary Responsibilities

This position reviews the clinical appropriateness of prior authorization (PA)/concurrent requests and ensures that all benefits authorized meet medical necessity and other Medicare guidelines to promote cost-effective delivery of health care services.

Essential Functions

• Review PA requests for home health services, durable medical equipment, outpatient therapies, skilled nursing facility therapies, and all outpatient procedures pursuant to applicable Medicare and Medicaid criteria, Interqual guidelines, and PA Department policies and procedures.
• Review PA requests for inpatient medical stays, skilled nursing facility stays, long term acute hospital stays, inpatient rehabilitation facility stays
• Participates with facility discharge planners, Care Coordinators/Care Managers in coordinating the member’s discharge needs.
• Monitors inpatient and subacute activity daily for outcomes related to readmission, utilization, quality of care and provider performance in compliance with TIHP policies.
• Provide complete and accurate documentation specifying rational for approval, r for forwarding to the CMO/Medical Director for further review.
• Create reduction/denial letters based on the Medical Director’s review and applicable guidelines.
• Maintain a thorough understanding of Medicare guidelines and stay abreast of updates and changes.

Work in collaboration with the PA staff to ensure timely and efficient completion of all workflows within the Department.

Educational/Training Requirements

• Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience.
• Knowledge of healthcare and managed care preferred.
• Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook
• Proficiency using Interqual criteria

Licensing Requirements

• Current unencumbered LVN or RN license in Texas or compact license.

Experience Requirements

• 3-5 years experience in Referrals/Authorizations
• 1 year insurance related experience in managed care environment.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.