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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

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Position:  PreCert/Concurrent Certification RN
Reports To: 
Division:  BANA Medical Affairs (2111)
Company:  ABCBS
Location:  Label
Job Code:  396216
Min Salary:   51000
Date Posted:  2/14/2013

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Position Specific Requirements: Must be willing to work between the hours of 6:00 a.m. - 10:00 p.m. Monday - Friday.


Job Summary
This position is accountable for reviewing in-patient admissions, concurrent facility stays, and op procedures for   ABCBS  and other contracted lines of business prior to and ongoing for the purpose of resolving medical, contractual, or technical issues/questions by applying evidence based criteria and corporate policies. Incumbent serves as consultant to Level I LPN’s to review and/or collaborate when review determination cannot be met based on initial clinical.

Nature & Scope
ENVIRONMENT
In order to enable the company to continue to meet the needs of its customers in a changing and competitive marketplace, the Utilization Management Nurse is required to adapt to constantly updated medical criteria and enterprise procedures, policies, and contracts. The organizational environment is one of teamwork and supportive relationships with team members.

WORK FLOW
This position receives telephone calls and faxed clinical to be reviewed directly by the Utilization Management Nurse for approval/disapproval. This position receives written and oral inquiries from Customer Service and Providers. The position collaborates and works very close with Customer Service, Care Management, and Nurse Navigators, Utilization Management Supervisor or Manager.

GUIDANCE
The incumbent must be self-directed and make active attempts to influence events to achieve goals. The incumbent   must have the ability to prioritize and make sound nursing judgments, utilizing evidence based criteria and computer systems/programs.

CHALLENGES
The challenges of this position are centered on the incumbent’s ability to properly define the direction in which to proceed with all areas related to the pre-certification process, including review of clinical documentation and comparing to guide lines to ensure the stay/procedure meets established criteria. The incumbent is also challenged with planning and organizing projects assigned directly to this position for completion within established timeframes under direction of the Utilization Management Supervisor or Manager

INTERFACES
The incumbent’s contacts within the Enterprise include: Professional and clerical staff, Customer Service, Care Management, Nurse Navigators, Utilization Management Supervisors, Utilization Management Coordinator, BANA Clinical Support & Utilization Manager, QPM, and the Medical Director for the coordination, processing and completion of work assignments and projects. The incumbent works with the UM Supervisors, UM Coordinator, BANA Clinical Support & Utilization Manager, and the Medical Director for implementation of and clarification of Corporate Medical Policy and its application to evidence based criteria, review of request for admissions, length of stay and concurrent length of stay in coordination with the nurse practice act.

AUTHORITY
The incumbent has the authority to make decisions regarding pre-certification and concurrent review using evidence based criteria guidelines established for the review of inpatient stays and op services. This position requires that these decisions be based on sound nursing judgment and a complete understanding of the relationship of contractual limitations and evidenced based standard/non-standard care in coordination with the nurse practice act.


This position requires excellent oral and written communication skills; the ability to make sound nursing judgments and decisions based on facts and guidelines, and the ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency. The incumbent demonstrates an ability to train and educate others on the current pre-certification processes under direction of the Utilization Management Supervisor.  The incumbent is to complete delegated or assigned projects, in a timely and organized manner, as delegated by the Utilization Management Supervisor and /or Manager.

Minimum Job Requirements

1. Registered nurse license, state of Arkansas, URAC Requirements.

2. RN experience in nursing to include a broad background in various facets of nursing OR  experience as an RN  as well as experience as a LPN with a broad background in various facets of nursing.

3. Experience with a health insurance organization in the area of medical review preferred.

4. Utilization management experience or background in medical economics preferred.

5. Surgical or critical care nursing background preferred.

6. Minimum typing speed of 40 WPM.

7. Strong communication, documentation, clinical, and critical thinking skills are essential.

8. Call center knowledge is desirable.

9. Directly related experience using Milliman criteria or healthcare criteria preferred.


Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Conduct telephonic review for all inpatient/outpatient facilities, and providers, for approval for contracted lines of business using Milliman criteria.
2. Attain performance standards as established in the business plan for the division.
3. Remains current with ongoing changes in billing and medical practice by use of evidence based guidelines and medical policy.
4. Maintain and update knowledge of new medical and surgical procedures and products, new drugs, and general trends in health care delivery.
5. Consult with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all product lines, Corporate Medical Director, Staff Attorneys, and others within the Enterprise under the direction of the Utilization Management Supervisor or Manager.
6. Initiate correspondence to physician, suppliers and hospitals requesting additional information on questionable inpatient admissions and out-patient procedures under the direction of the Utilization Management Supervisor or Coordinator.
7. Works collaboratively with all other teams within the division acting as a  mentor or reference for the UM LPN.              8. Must become knowledgeable of URAC requirements for clinical staff for UM accreditation.
9. Collects only pertinent clinical information and documents all UM review information using the appropriate software system.
10. Communicate directly with physician providers/designees, when appropriate, to gather all clinical information to determine the medical necessity of requested healthcare services.                                              
11. Communicate directly with the Utilization Management Supervisors and/or UM  Manager regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues for referral to the Medical Director.
12. Participates in UM program CQI activities.
13. Follows mandated time frame standards for conducting and communicating UM review determination.
14. Identifies and communicates to the Utilization Management Supervisor or Manager, all hospital, ancillary provider, physician provider and physician office concerns and issues.
15. Maintains courteous, professional attitude when working with internal and external customers, hospital and physician providers.
16. Active participation in team meetings and Individualized meetings.
17. Perform other duties as requested by the Utilization Management Supervisors, Manager, or any upper management personnel.

Customer Services-Internal

• Supports a positive working environment
• Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Utilization Management Supervisors or Manager while following the chain of command, as a resource.
• Communicates to the Utilization Management Supervisors or Manager all problems, issues and/or concerns as they arise.
• Communicates to the Utilization Management Supervisors, Coordinator, or Manager any issues or concerns related to qualify of care.
• Maintains a courteous and professional attitude when working with all staff members and the management team.
• Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role.
• Actively participates in team meetings, as designated.




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