ISNP Utilization Management Nurse

Job Summary: The ISNP Utilization Management Nurse is supervised by a Utilization Management Supervisor and is responsible for evaluating a members clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for inpatient and outpatient services based on independent analysis of those medical records and application of appropriate medical necessity criteria.

The ISNP Utilization Management Nurse is empowered make clinical determination decisions by independently authorizing services deemed medically necessary based on the independent review using InterQual, MCG, National and Local Coverage Determination Guidelines and to refer and consult with a medical director for those services that do not meet medical necessity criteria.

The ISNP Utilization Management Nurse directly interacts with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria and policies for the company and its customers, as well as assisting management with development of short- and long-term business objectives.

Throughout the performance of their duties, the ISNP Utilization Management Nurse provides a front-line regulatory/compliance function in their evaluation and application of the criteria.

The ISNP Utilization Management Nurse is supported by administrative staff responsible for compiling information, data entry and other tasks to build cases and facilitate their work so that the ISNP Utilization Management Nurse can focus the majority of their time on applying their medical knowledge to medical necessity reviews.

This job description is intended to provide a general overview of the position, while recognizing that actual day-to-day duties may vary for the ISNP Utilization Management Nurse depending on individual factors such as education, experience, skills, supervisor, and caseload.

Key Tasks and Responsibilities: Receives requests for authorization of services, including inpatient hospital admissions, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination) in the Health Plan designated system accurately and timely.

Verifies and documents member eligibility for services.

Communicates and interacts on a real time basis via live encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).

Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities.

Applies Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

Applies submitted information to Plan authorization process (utilizing Interqual, MCG, NCDs, LCDs or medical guidelines, Process Standard...