Job Description

Job Description

Job Description

Job Summary:Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with regulatory benchmarks, ensuring precision and compliance in medical record reviews. This role will include Utilization Review/Management (UR/UM) across a variety of service areas, such as Durable Medical Equipment (DME), acute care, inpatient admissions, third-party outpatient (TPO) services, imaging, genetic testing, and other medical services.Responsibilities:

• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for quality monitoring activities.
• Maintains current knowledge base related to review processes and clinical practices related to the review processes; functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
• Functions as providers' liaison for customer service issues and problem resolution.
• Performs all applicable review types (including DME, acute, inpatient, outpatient, imaging, genetic testing, etc.) as workload indicates.
• Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Attends training and scheduled meetings for current/updated information.
• Cross trains and performs duties to provide flexible workforce to meet client/customer needs.
• Reads, understands, and adheres to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

• Active, unrestricted Registered Nurse (RN) license issued by the State of Illinois
• A minimum of a diploma, certificate, or degree in Nursing.
• 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.
• Experience reviewing medical necessity for services including DME, acute care, inpatient, TPO, imaging, genetic testing, and other related categories.
• 1+ years of knowledge of InterQual criteria, Milliman Care Guidelines (MCG), and/or other state/nationally recognized criteria.
• Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Flexibility and strong organizational skills.

• An Associate, Diploma, or Bachelor’s degree from an accredited college or university in Nursing or a related field.
• Knowledge of current National Committee for Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Ability to work in a team environment.
• Proficient in Microsoft Office.
• Efficient time management, including the ability to prioritize tasks and meet deadlines.
• Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.

Attention Applicants: Please be advised that proper email communication will only be sent from email addresses ending in @astyra.com. Please ensure you are communicating with approved Astyra recruiters by checking this point when receiving offers and messages from us. It is important to communicate within our guidelines and proper channels to expedite possible interview considerations.

#AC

Job Tags

Similar Jobs