Utilization-Concurrent Review Nurse (Clinical Reviewer)

Care Centrix Hartford, CT

Overview:

The core function is to review utilization information concerning patient care for CareCentrix, and to match those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria. Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge. This position, using clinical expertise, receives/responds to incoming calls from referral sources/potential clients and CareCentrix Care Coordinators and performs administrative assessments of each referral’s appropriateness for CareCentrix services. Researches/identifies all potential payer sources and determines the primary payer. Participates in utilization and quality assessment/improvement activities. Works under moderate supervision.

Responsibilities:

• Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills.
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• Reviews and adheres to all Company policies and procedures and the Employee Handbook.
• Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria.
• Verifies completed case verifications funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.
• Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients’ needs and determines CareCentrix' ability to meet them.
• Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues.
• Holds all referrals until all information is verified as complete and the next steps are determined.
• Records the outcome of all inquiries and referral calls received, and makes follow - up calls when an inquiry or referral cannot be serviced. Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available.
• Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and determines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner.
• Recommends to Team Leader - Intake the acceptance of referrals that do not meet CareCentrix guidelines as appropriate. Coordinates internal activities to ensure a smooth transition from CareCentrix to the provider.
• Develops/maintains a working knowledge of all CareCentrix services and accesses CareCentrix contract information, including the terms of the contract as appropriate. Interacts with referral sources to facilitate communications, answer questions and resolve problems.
• Participates in ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.
• Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates. Follows Utilization Management and URAC standards.
• Attends/participates in staff development programs and obtains continuing education as required by company policy. Provides back up support to the Team Leader to ensure that intake operations are maintained.
• Participates in special projects and performs other duties as assigned.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.

Qualifications:

Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and Registered Nurse/LPN/LVN (based on allowable state practice act) licensure in the state(s) of practice required. Minimum of 2 years of experience. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred. Excellent negotiation, communication, problem solving and decision making skills also preferred. Excellent knowledge of Utilization Management and URAC standards. Licensed professionals are required to possess a current license to practice without restrictions.

CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.