使用率审查护士
Utilization Review Nurse
欢迎！我们很高兴您考虑加入我们！要申请此职位并被考虑，请点击本消息上方的“申请”按钮，并完整填写申请表。以下是你将找到的有关此职位的其他重要信息。
与医疗总监合作，推动护理差异的减少，确保及时出院，并将成员转介至其他计划资源以满足其护理需求。向利用管理健康计划经理汇报。此职位将是健康计划医疗管理团队的重要成员。此职位是医疗管理团队的协作成员。
最低资格要求：
教育、认证和/或执照：
1. 在提供服务的州获得的当前注册护士执照，或通过增强型护士执照互认协议（eNLC）获得的多州注册护士执照。
经验：
1. 三年医疗临床经验。
优先资格：
教育、认证和/或执照：
1. 护理学士学位或护理科学副学士学位（ASN）；正在攻读护理学士学位，并在入职后三年内完成学士学位。
经验：
1. 为医疗保险和/或医疗补助人群提供医疗管理的经验。
2. 利用管理经验。
核心职责和责任：此处描述的陈述旨在描述分配到此职位的人员所从事的一般工作性质。它们不打算被解释为所有职责和职责的详尽列表。可能会分配其他职责。
1. 协助建立和实施符合既定行业和公司标准的护理管理审查流程（事先授权、预确定、同期审查、回顾性审查）。
2. 协助根据接受和既定的标准以及其它临床指南和政策建立和实施所有护理管理审查。
3. 确保干预措施具有协作性，并专注于最大化成员的医疗成果。
4. 理解同行评审流程，并与医疗总监合作，持续改进该流程的成员和供应商网络服务。
5. 教育内部和外部的利益相关者和合作伙伴，持续改进流程并建立网络关系。
6. 协作工作
查看英文原文
Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.
Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team.MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
EXPERIENCE:
1. Three (3) years of healthcare clinical experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
EXPERIENCE:
1. Medical Management for Medicare and/or Medicaid populations.
2. Utilization Management experience.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.
6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
7. Understands the data that is collected within the position, and work with other team members on improving outcomes.
8. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
SKILLS AND ABILITIES:
1. Working Knowledge of InterQual and/or Milliman Care Guidelines.
2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.
3. Excellent written and oral communication.
4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.
Attention to detail.
5. Proficiency with Microsoft Office.
Additional Job Description:
This role may require occasional weekend and holiday work.
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Exempt)Company:
PHH Peak Health HoldingsCost Center:
2403 PHH Medical ManagementOriginally posted on Himalayas