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*                                                                      Position Description:* *  QA Utilization Management Review Nurse*

Reporting to the QA Utilization Management Review Lead, the QA Utilization Management Review Nurse will provide an independent, professional assessment, monitoring and evaluation of medical records and associated medical review documentation to ensure consistency in decision making among select Medicare contractors. The QA Utilization Management Review Nurse will follow established guidelines, policies, and procedures to review Medicare beneficiary requested appeals and short stay claims determinations to measure the level of agreement between the initial contractor decision and PRITM as the oversight entity.   In addition, the QA Utilization Management Review Nurse will use a standardized process and screening tool to assess medical records for identification of potential triggers that may be indicative of an adverse event.

Responsibilities:

• Understand and represent PRITM's mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRITM staff in a professional and accountable manner, and as a representative of PRITM management
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM's ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement
• Perform medical record review in accordance with all State, Federal and/or commercially mandated regulations
• Maintain compliance with all regulation and policy changes as they impact medical and utilization review practices
• Review patient records and associated review documentation and participate in interdisciplinary collaboration with PRITM staff and all recognized teaming partners and/or subcontractors
• Document all review information utilizing the appropriate Medical Review form, report and/or system.
• Clearly and succinctly document rationale for all cases requiring referral for physician review
• Utilize electronic health information imaging
• Utilize Internet and Intranet resources for applicable research, e.g., evidence-based standards of care guidelines, Internet-only manuals, quality measures, etc.
• Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicable
• Understand and represent PRI's mission, vision, and values to all internal and external customers
• Perform other duties as requested

Requirements:

• Bachelor's Degree in Nursing (BSN), MSN preferred
• Requires a minimum of three (3) years' experience in a clinical nursing role plus minimum of one (1) year additional experience performing utilization/quality assurance reviews in health care provider setting
• Additional knowledge and experience with CMS Quality Improvement Organization (QIO) case review program preferred
• Experience using Institute for Healthcare Improvement (IHI) Trigger Tool highly desirable
• Must be a Registered Nurse (RN) with an active license in state of residence
• Broad knowledge base of health care delivery and case management within a fee for service and managed care environment
• Comprehensive knowledge of medical necessity standards, lev ls of care, inpatient and outpatient status and utilization review/quality assurance in healthcare provider setting
• Extensive knowledge of state and federal healthcare regulations and policies,
• Excellent writing and communication skills
• Knowledgeable of quality measures and National Quality Strategy
• Knowledgeable of ICD-9-CM/ICD-10-CM, CPT-4 and HCPCS coding desirable but not required
• Knowledge of Microsoft office suite such as Outlook, Access, Excel and Word
• Certification in quality improvement/quality management, and/or utilization management/review preferred
• One year or more of utilizing InterQual and/or Milliman guidelines is preferred
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
• Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)

• Ability to obtain and maintain U.S. Government Security Clearance

   

Preference will be given to individuals who reside in, or are willing to relocate to, a recognized HUBZone area.  (Go to http://map.sba.gov/hubzone/maps/ for more information).

FLSA Status:  Exempt

The PRITM  Team Member Compensation Plan is applicable to this position

PRI is an equal employment opportunity employer.  All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

Qualified candidates may apply by clicking, "Apply Now". Next, submit your resume. You may complete a cover letter on the following screen. *You must contact the employer via one of the methods listed on the screen after clicking "Apply for this job". * Please be sure to identify PA CareerLink as your referral source.