Grand Junction, CO
The UM Nurse evaluates the appropriateness and necessity of medical treatment through the Utilization Management review process in order to promote quality, outcome-based medical care while providing world-class service to customers in an accurate, efficient and courteous manner.
Duties and Responsibilities
- The job holder will work with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks:
- Performs utilization management reviews in accordance with federal and state mandated regulations. Maintains compliance with regulatory changes affecting utilization management.
- Perform UM reviews (prospective/concurrent/retrospective) for inpatient/ outpatient services according to the URAC standards and client requirements and/or policies.
- Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer.
- Adheres to Department of Labor, state and company UM timeframe requirements
- Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
- Tracks status of all utilization management reviews in progress
- Releases UM determinations to claim stakeholders following client-established protocols.
- Works closely with management team in the ongoing development and implementation of utilization management programs.
- Certifies reviews that meet clinical review criteria/guidelines.
- Adheres to quality standards and state UM guidelines
- Maintains all required utilization management review documentation in the UM software in a timely manner.
- Serves as first level contact for customer complaint resolution.
- Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
- Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.
- Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
- Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
- Learns new methods and services as the job requires
- Advises supervisor of any potential problems as they become evident.
- Manages assigned workload within established performance standards.
- Attends meetings to achieve departmental goals and objectives.
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