Job Description

Join Martin's Point Health Care

An innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position includes reviewing prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completing inpatient concurrent review, establishing discharge plans, coordinating transitions of care to lower/higher levels of care, making referrals for care management programs, and performing medical necessity reviews for retrospective authorization requests as well as claims disputes.

Job Description

Key outcomes include:

• Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity.
• Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
• Manage the review of medical claims disputes, records, and authorizations for billing, coding, and compliance.
• Collaborate with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources.
• Coordinate referrals to Care Management, as appropriate.
• Manage health care within the benefits structures per line of business and perform functions within compliance, contractual, and accreditation regulations.
• Complete all documentation of reviews and decisions, in appropriate systems, according to process/compliance requirements and within timeliness standards.
• Participate as a member of an interdisciplinary team in the Health Management Department.
• May be responsible for maintaining a caseload for concurrent cases/assisting in caseload coverage for the team.
• Establish and maintain strong professional relationships with community providers.
• Act as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time.
• Mentor new staff as assigned.
• Maintain quality audit scores within department standards.
• Maintain productivity within department standards.
• Assist in creation and updating of department policies and procedures.
• Participate in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
• Participate in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
• Demonstrate flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
• Assume extra duties as assigned based on business needs, including weekend rotations.

Education/Experience

3+ years of clinical nursing experience as an RN, preferably in a hospital setting. Utilization management experience in a health plan UM department.

Required License(s) and/or Certification(s)

Compact RN License. Certification in managed care nursing or care management desired (CMCN or CCM).

Skills/Knowledge/Competencies (Behaviors)

Demonstrates an understanding of and alignment with Martin's Point Values. Maintains current licensure and practices within scope of license for current state of residence. Maintains knowledge of Scope of Nursing Practice in states where licensed. Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately. Ability to analyze data metrics, outcomes, and trends. Excellent interpersonal, verbal, and written communication skills. Critical thinking: can identify root causes and understands coordination of medical and clinical information. Ability to prioritize time and tasks efficiently and effectively. Ability to manage multiple demands. Ability to function independently. Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org

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