Job Description

JOB SUMMARY

The Quality & Post Payment Review Nurse is responsible for reviewing prior authorization requests for medical services including elective procedures, outpatient surgeries, home health, and durable medical equipment. The nurse will prioritize expedited requests for medical necessity and efficiency in accordance with health plan coverage guidelines and CMS coverage determinations. Demonstrates proficiency in the application of national and local clinical case review criteria for precertification requests. Ensures compliance with all delegated and regulatory requirements. The nurse works under the direction of and collaboratively with the UM Team Lead and physician reviewers for questionable medical necessity codes and issuance of denials including Integrated Denial Notice (IDN), Notice of Medicare Non-Coverage (NOMNC), Detail Explanation of Non-Coverage (DENC), and follow the Health Plan appeal process & Quality Improvement Organization (QIO) process. The nurse will conduct quality assurance/audits of UM team members' decisioned authorizations to ensure the appropriate application of HTA’s PAL (prior authorization list), CMS NCD’s and LCD’s, Health Plan criteria, and HTA’s Evidence of Coverage. Works collaboratively with UM staff, Health Plan, and TPA (Claims Department) to identify, quantify, and measure opportunities for improvement. Projects and activities are focused on CMS Medicare Managed Care UM requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES

This position must be able to:

Utilization Management Adjudication

• Supports the Collaborative Utilization Management Model as a working partner with physicians, social workers, pharmacists, and other professional staff. Demonstrates proficiency in the application of national and local clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events.
• Reviews high-risk, problem-prone post-service cases when requested to ensure clinical documentation supports medical necessity prior to payment of services. Identifies trends, recommends corrective actions, and completes follow-up audits to ensure compliance.
• Establishes priorities during routine daily operations, addressing time-sensitive reviews/matters first, while also accomplishing day-to-day tasks and duties. Effectively triages tasks and events according to urgency level, impact on patients, and outcomes desired under special conditions (e.g., during crises and emergencies). Makes choices that result in maximum completion of essential duties and minimum personal stress.

Regulatory Compliance

• Ensures complete and accurate documentation in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
• Audits UM pre-certification records to ensure compliance with CMS and NCQA UM requirements and internal policies. Identifies trends, recommends corrective actions, completes follow-up audits to ensure compliance, and assists with UM staff training.
• Aids in preparation, presentation, and follow-up of all CMS and/or Health Plan Part C ODAG audits. Works collaboratively with the Health Plan compliance department to ensure all milestones/timelines are met with respect to Part C audit requirements.
• Ensures compliance with regulatory turnaround times & HIPAA (Health Insurance Portability and Accountability Act).

Customer Service

• Works collaboratively with requesting providers to ensure quality and appropriateness of care is being provided to members. Aids in post-inpatient discharge review when requested. Provides guidance and assistance with complex care cases to identify barriers, develop action plans, and program modifications for change.
• Demonstrates the ability to develop departmental relationships with internal and external customers to provide exemplary service and achieve goals.
• Demonstrates participation in multi-disciplinary team rounds to address utilization/resources and progression of care issues, and assist in developing and implementing an improvement plan to address issues.
•  Perform other duties as assigned

EDUCATION AND EXPERIENCE

Education:

• RN or BSN
• Current NC RN licensure in good standing
• Annual Flu Vaccine

Required Experience:

• 3 years of utilization management experience with
• 2 years of quality assurance and improvement

Preferred Experience:

• Certified Professional in Healthcare Quality (CPHQ)
• Health Plan UM experience
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of national and local coverage determinations and managed care requirements.

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• Exerting up to 20 pounds of force occasionally (up to 1/3 of the time), and/or;
• up to 10 pounds of force frequently (1/3 to 2/3 of the time), and/or:
• a negligible amount of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible
• Exerting 20 to 50 pounds of force occasionally (up to 1/3 of the time), and/or;
• 10 to 25 pounds of force frequently (1/3 to 2/3 of the time), and/or
• Greater than negligible up to 10 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting 50 to 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• 25 to 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• 10 to 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Exerting in excess of 100 pounds of force occasionally (up to 1/3 of the time), and/or;
• in excess of 50 pounds of force frequently (1/3 to 2/3 of the time), and/or;
• in excess of 20 pounds of force constantly (2/3 or more of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.

Benefits from Day One:  

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.

ABOUT HEALTHTEAM ADVANTAGE

HealthTeam Advantage is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.  

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