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Utilization Management Reviewer RN

Company: Blue Cross Blue Shield of ND
Location: Fargo
Posted on: December 4, 2019

Job Description:

Employer Blue Cross Blue Shield of ND Location Fargo, North Dakota Salary Join our team! Posted Nov 19, 2019 Ref UTILI01554 Industry Healthcare Role Manager Job Type Long-Term Hours Full Time You need to sign in or create an account to save Job Summary The Utilization Management Reviewer (RN) processes pre-service requests in a timely and accurate manner reviewing requests for completeness and for appropriate insurance coverage. This position selects from and uses multiple data sources to make a medical necessity determination and may refer to medical review or case management. The Utilization Management Reviewer (RN) responds to the provider with a decision and rationale discussing the case, providing additional information and explanation for the decision, if necessary. Essential Functions Considers and identifies multiple factors to determine the level of medical review necessity, this includes, but is not limited to: reviews member and benefit eligibility, conducts medical necessity for preauthorization, prior approval and courtesy predetermination requests and applies medical policy and evidence based medicine guidelines and research in the absence of an established policy or guideline. Requests additional documentation and clarifies information to substantiate utilization management decisions as per the standard nursing process for assessment and evaluation. Completes all necessary documentation to relay decision. Communicates decision in written form for rejections, follows up directly with provider to explain and discuss. Identifies trends and aberrancies related to medical necessity and utilization patters. Serves as a medical resource for the organization and provide guidance and direction on matters such as workflow processes and criteria development as related to medical policy and utilization management. Collaborates with internal staff and external providers to provide outcome, refer to complimentary programs and provides additional instruction. Monitors for under and over-utilization practice patterns. Prioritizes workloads to ensure timeliness standards and inventory levels are maintained. Knowledge, Skills and Abilities Attention to Detail and Accuracy Advanced Communication (Verbal/Written) Intermediate Nursing Expertise Advanced Task and Goal Focus Intermediate Analytical Thinking Intermediate Education Requirements Required: Associate's Preferred: Bachelor's Field(s) of Study: Completion of RN program is required; BSN is highly preferred Experience Requirements Required: Minimum of 3 Years Preferred: Minimum of 5 Years Experience Details: Minimum of 3 years of clinical/patient care or related experience is required; variety of clinical, hospital, skilled nursing experience is highly desirable; candidate must possess in-depth medical knowledge, critical thinking skills and expertise in interpretation and application of medical policy/criteria, utilization management processes, medical criteria/guidelines, contract benefits and the ability to research medical diagnoses, procedures and technology. Certification, Licensures & Registration Requirements Title: North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND State or Agency: Board of Nursing Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards Other Information Job Posting Policy 6.05 New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply. Equal Opportunity Employment Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity. For questions, please email ****************** This job posting will be closed 12/3/2019 at 8:00AM CST. No further applications will be considered.

Keywords: Blue Cross Blue Shield of ND, Fargo , Utilization Management Reviewer RN, Executive , Fargo, North Dakota

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