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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

Position:  RN Utilization Management
Reports To: 
Division:  BANA Medical Affairs (2111)
Company:  ABCBS
Location:  Label
Job Code:  396216
Min Salary:   59000
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
The Utilization Review Nurse is accountable for clinical review to assist ABCBS members, and other contracted lines of business prior to, and during inpatient admissions, and outpatient procedures. The role evaluates the efficiency and appropriateness for inpatient stays and outpatient procedures for medical necessity through review with evidenced-based criteria of clinical guidelines and policies. The incumbent promotes quality toward cost effective outcomes based on evidence.  Incumbent serves as a consultant to LPNs to review and /or collaborate when review determination cannot be met based on initial clinical review.

Nature & Scope
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.

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.

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 through critical thinking, utilizing evidence based criteria and computer systems/programs.

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

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.

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,

2. RN experience in nursing to include a broad background in various facets of nursing such as medical-surgical nursing, surgical nursing, intensive care nursing, or critical care nursing.  

3. Experience with a health insurance organization in the area of medical review preferred. Experience using healthcare criteria for medical necessity preferred.

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

6. Above average keyboarding skills.

7. Average PC skills.

8. Excellent interpersonal skills and above average communication skills.

9. Strong documentation, clinical, and critical thinking skills are essential.

10. Call center knowledge is desirable.

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.

1. Facilitates appropriate cost effective and cost containment measures.

2. Adhere to URAC Standards.

3. Adhere to state mandates for all states represented by members and Federal regulations for all UM reviews.

4. Making decisions based on facts and evidence assuming responsibility for those decisions

5. Practice utilization management activities within the scope of practice.

6. Serve as consultant to LPNs to review and/or collaborate when review determination cannot be met based on initial clinical review.

7. Cooperate and work effectively with all department and division staff to facilitate services to members and providers of care.

8. Remains current with medical and surgical procedures, products and general trends in health care delivery.

9. Remains current with ongoing changes medical practice by use of evidence based guidelines and medical policy.

10. Participates in continuous quality improvement activities.

11. Communicate directly with internal and external physicians and facilities (such as hospitals, long term acute care facilities and skilled nursing facilities) providers/designees for the medical necessity of healthcare services.

12. Collaborate with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all product lines, Corporate Medical Director, Staff Attorneys, and Case Managers within the Enterprise under the direction of the Utilization Management Supervisor or Manager.

13. Monitor cases for medical necessity, quality of care and level of care.

14. Work incoming calls from providers and facilities daily.

15. Work assigned outbound calls to providers and facilities daily.

16. Maintain continuous, effective communication with internal and external stakeholders

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