• Utilization Review RN

    Job Locations US-VA-Glen Allen
    Job ID
    2018-5390
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.  By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    Responsible for authorizing cases according to approved criteria across the continuum of care to ensure a positive patient outcome while controlling costs by performing inpatient and outpatient reviews, and identification and referral of patients appropriate for case management.

    Responsibilities

    • Obtains, review and enters clinical information from callers and on-site reviews according to VPHP’s policy and procedure manual for medical/behavioral health services requiring certification such as: pre-admission, admission, concurrent and retrospective review in VPHP’s computer systems.
    • Develops a complete understanding of and keeps current with customer requirements and uses knowledge as appropriate in utilization review process.
    • Reviews pre-certification requests within 1 business day of receipt to determine the medical necessity and appropriateness of care using established criteria. Refers questionable cases to the Medical Director .
    • Prepares and sends the appropriate certification or non-certification letter to the member, provider and hospital according to Virginia Premier Health Plan, Inc. (VPHP) policies and procedures.
    • Refers potential high-risk cases which will benefit from case management services to case management.
    • Interfaces with multidisciplinary staff to identify social factors impacting members’ illness and treatment.
    • Communicates effectively with customers while recognizing their various requirement and level of expertise with managed care.
    • Assesses social, economic, environmental and emotional factors that interfere with patient and family adjustment to illness and treatment and collaborate with case management to develop a plan of care.
    • Identifies and obtains needed community resources and provides feedback to external agencies on specified cases, as necessary.
    • Assist in the coordination of the psychosocial aspects of a member’s care plan.
    • Participates in VPHP’s ongoing quality improvement process.
    • Participates in continuing educational activities as appropriate.
    • This position provides services and demonstrates the knowledge and ability to meet the specific needs of all age groups.

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS 

    • Current Virginia RN Licensure with demonstrated experience in Utilization Review; BSN preferred.

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees.
    • Demonstrates ability to negotiate with providers, vendors and other deliverers of services.
    • PC literate with working knowledge of Microsoft Word, Excel spreadsheet programs, and various computer software programs.
    • Working knowledge of resource options, and experience in making appropriate referrals.
    • Possess a working knowledge of ICD10 and CPT-4 coding.
    • Current Utilization Review experience.

    WORK BACKGROUND/EXPERIENCE

    • Minimum of three years clinical experience and/or current managed care experience.

    PHYSICAL REQUIREMENTS 

    • Physical health sufficient to meet the ergonomic standards and demands of the position.

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

     

    Our mission is to inspire healthy living within the communities we serve!

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