UTILIZATION REVIEW NURSE NEEDED IN W. HOLLYWOOD,CA!!!

Performs pre-admission, concurrent and retrospective acute care, sub-acute, hospice, and transitional care reviews to determine whether or not an admission is, or remains to be, reasonable and medically necessary using established criteria, e.g., Milliman and Robertson, InterQual or Best Practice criteria.

Performs case reviews in a timely manner with case notes in the appropriate database.

Collaborates with the Primary Care Provider and/or attending physician, internal and external case managers, and other appropriate health care team members to provide continuity and quality of care in the most cost effective manner.

Assists in the discharge planning process with both internal and external case managers/ discharge planners

Concurrent Review and collaboration with internal case managers of all acute care, skilled nursing, acute rehabilitation, long term care, hospice and home with home care services admissions

Assesses each acute care hospital admission to determine the appropriate level of care, i.e., critical care, telemetry, step down, medical-surgical, administrative, etc.

Performs Admission Review within 24-48 hours of admission

Monitors and maintains Length of Stay Reports

Attends In-Patient Rounds at the Plan’s Preferred Hospitals

Identifies and reports “Lag Days” and variances to the Director of Utilization Review and Case Management

Coordinates closely with the Plan’s Medical Director, referring cases that do not appear to meet established criteria

Compiles and analyzes data for utilization review management activities

Maintains logs and statistics.

Reviews and issues Prior Authorizations for Pharmacy Services Program

Prepares and distributes weekly, monthly, quarterly and yearly utilization review reports

Prepares Ad hoc reports upon request

Prepares an annual Utilization Review Program evaluationGraduate from an accredited RN Program with 3 or more years of recent medical/surgical or HIV/AIDS nursing experience and 3 or more years of recent Utilization Review / Case Management experience.

Computer/Software Skills & Abilities:

To perform this job successfully, an individual should have knowledge of Contact Management systems, Word processing software, and Spreadsheet software.

Other Skills:

•Strong telephonic skills for reviews.

•Ability to successfully work with various levels of professional staff

•Must be able to work independently and as part of a team.

•Knowledge of HIV/AIDS and related medical and patient care issues and concerns in diverse populations.

Certificates, Licenses and Registrations:
•Current California RN License