Utilization Management Nurse, Senior

Your Role

The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their families  . The FEP Concurrent Review Utilization Management Nurse will report to the FEP Utilization Management Manager. In this role you will be  part of a dynamic team responsible for concurrent and retrospective reviews from inpatient admissions to both acute and lower level of care. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit in full collaboration with FEP Care Management. Ultimately contributing to decreasing the cost of healthcare.   

Your Work

In This Role, You Will:

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for the FEP PPO line of business
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance for IP, outpatient and lower level of care  
• Ensure discharge(DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning 
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
• Actively participates in staff meetings and huddles 
• Provides input into desk level procedures.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience 
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• Previous experience in utilization management preferred
• Strong computer skills related to Windows-based programs and applications
• Varied acute care clinical background that includes behavioral health experience
• Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision