Utilization Review Nurse

Description:

Responsibilities:

• Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Data gathering requires navigation through multiple system applications.
• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Responsible for the review and evaluation of clinical information and documentation.
• Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
• Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
• Independently coordinates the clinical resolution with internal/external clinician support as required.
• Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
• Prepares and completes QM documents based on interpretation and application of business requirements
• Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
• Assists in the development and implementation of QM projects and activities
• Accountable for completing and implementation of QM Work Plan Activities

Experience:

• 3+ years of experience as an RN
• Registered Nurse in state of residence
• Must have prior authorization utilization experience
• Experience with Medcompass