Concurrent Nurse Reviewer - Facility Utilization Review Unit

1. Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations as described in the Medical Management UM work plan.

This detailed clinical judgment includes determination of inpatient hospital stays as medically appropriate for the member's clinical condition or whether the stay requires referral to a Medical Director for potential denial.

The Nurse Reviewer must follow each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admission.

Responsibilities include using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

Promote improved quality of care and/or life

Promote cost effective medical outcomes

Prevent hospitalization when possible and appropriate

Promote decreased lengths of hospital stays when appropriate

Ensure the quality-of-care member is receiving during hospital stay is appropriate

Ensure appropriate levels of care are received by patients

Consult with Medical Directors on potential quality issues encountered during review of medical records in situations when the complexity of the member's medical, surgical and/or pharmaceutical management is unclear and may require further review or intervention and follow up with attending physicians, hospitalists, or other facility staff 2. Provide appropriate consultation and referral to Case Management or QUEST Integration program as appropriate 3. Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available inpatient and community resources. 4. Identifies cost savings and accurately records all communications and interventions. 5. Evaluates suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc. 6. Communicates timely, accurate information either verbally or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to internal MM staff, other internal departments (Claims Administration, Customer Relations, etc.), providers, members, and other authorized persons.

For denied services, ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation, and regulatory guidelines. 7. Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed. Also identifies and refers quality of care issues and suspected fraud, waste, or abuse to the appropriate departments. 8. Performs all other miscellaneous responsibilities and duties as assigned or directed.