GENERAL SUMMARY
Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with client’s-specific contract rules and guidelines and with
company’s policies, practices, and procedures to facilitate quality and cost effective care for the injured employee.
ESSENTIAL RESPONSIBILITIES
- Performs utilization review activities including pre-certification, concurrent, and retrospective reviews according to guidelines.
- Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing state or state recommended guidelines (if available).
- Assists with the negotiation of the appropriate length of care or alternative level of care when allowed by state jurisdiction.
- Refers case to a review physician when the treatment request does not meet necessity per guidelines, when guidelines are not available, or per customer account instructions. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within state or URAC mandated turn around times.
- Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider, claim payer, claimant, and claimant’s attorney.
- Coordinates the appeal process as applicable with requesting and utilization review physician.
- May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
- Performs other duties as assigned.
Qualifications:
JOB SPECIFICATIONS
- Active Licensed Practical Nurse (LPN) license required.
- Minimum of 3 years clinical practice experience required.
- UR experience preferred but not required.
- Previous managed care and/or utilization review experience preferred.
- Strong problem solving and analytical skills.
- Excellent communication, organizational, and interpersonal skills.
- Proficiency with standard software applications including spreadsheets and word processing.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Administrative Support Workers
Primary Location: Tampa, FL, US
Organization: 43000 - CHC Workers Compensation
Schedule: Full-time
Job Posting: 2013-01-09 00:00:00.0
Job ID: 1310096