Transitional Care Utilization Review - Work From Home (In Area)
Transitional Care Utilization Review RN
***Fully Remote with Washington, DC license***
** Requires occasional travel into DC **
- Apply clinical review criteria, guidelines, and screens to determine the medical necessity of health care services.
- Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
- Refer cases to other professionals internally, including medical affairs consultation, as well as to customers and other appropriate external sources when indicated.
- Provide clinical and/or review process subject matter expertise; manage complex reviews, respond to customer requests or complaints; monitor and report pertinent observations of clinical performance.
- Provide initial clinical orientation to new employees as well as ongoing clinical mentoring and support for clinical review staff.
- Collaborate with the clients to provide clinical expertise on complex cases and or process clarification.
- Collaborate with Medical Affairs for complex case review and clinical topics.
- May perform quality assurance audits and program support as assigned.
- Report HIPAA and or PHI violations in the appropriate Freshservice database
- As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees performance of these activities.
- Bachelor's degree in nursing or related field
- Washington, DC RN license in good standing
- 3+ years experience with InterQual.
- Occasional Travel to Washington, DC office, must live within reasonable driving distance.
- Utilization Review or Utilization Management experience for Medicaid patients strongly preferred.
- Ability to conduct an assessment including identifying strengths and needs, life domain functionals, risk, cultural factors, behavioral and emotional needs; assess trauma and substance use, health and safety risks to self or others, gathering histories of mental and physical health, substance use, past mental health services, assessing care giver resources and needs, social and work relationships; community based person centered plan review experience, community based elderly persons with disability service experiences, nursing home quality chart review with Minimal Data Set ( MDS) skill set experience.
- Proficiency with ZeOmega's Jiva medical management system preferred.