Employment Spot

Job Description

About Us:

Community Health Plan was established in 1992 by a network of community health centers across Washington State. We provide coverage for people in 33 counties (see our clinic site list). Our members receive services from more than 1,000 primary care providers and 8,000 specialists at more than 250 primary care sites and over 80 hospitals. We're the fifth-largest health program in Washington (commercial or non-profit).

Key Relationship

Reports To: Medical Director

Supervises: Non-Supervisory

Other Key Relationships: Pharmacists, Provider Services, Grievance and Appeals staff, Operations staff.

FLSA: Exempt

Position Purpose of Utilization Management Retrospective Review Nurse

Performs Utilization Management (UM) Program activities with special focus on retroactive review of inpatient stays to establish medical necessity for level of care and length of stay.

Responsibilities of Utilization Management Retrospective Review Nurse

Principle Duties

• Performs medical necessity reviews of submitted medical records and claims for services already provided and serves as resource to other members of the utilization review team.
• Consults with Medical Director, Chief Medical Officer or physician designee as needed to make medical necessity determinations about what??
• Assures contractual turnaround timelines are met on clinical determinations; maintains appropriate documentation of all activities.
• Assures accurate and appropriate communication occurs to providers and members, provides clarification and feedback, as needed, on coverage determinations.
• Partners with operations staff to effectively perform medical claims reviews as assigned.
• For retrospective reviews, performs pre-existing condition (PEC) determinations and out of benefit determinations
• Provides education and coaching for both CHP and contracting facility staff regarding appropriate use of concurrent review guidelines.
• Assists and supports all related processes, including development of policies and procedures and process improvement efforts as assigned.
• Other duties as assigned.

Job Requirements

Requirements of Utilization Management Retrospective Review Nurse

Qualifications

Education

• Current State RN or LPN license required.
• Bachelor’s Degree in Nursing or other Health care related field preferred

Prior Related Experience

• 5+ years clinical nursing experience.
• 2+ years experience with medical claims review and/or inpatient concurrent review.
• Experience working in a managed care environment preferred.

Employment Eligibility

• Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

Knowledge, Skills, and Abilities

• Knowledge of medical necessity principles, including use of clinical criteria; preferably Milliman Care Guidelines
• Strong organizational skills and accurate work results.
• Computer literacy, including familiarity with Windows and Microsoft Office programs
• Ability to work independently, efficiently and with excellent time management skills
• Excellent communication skills, both verbal and written
• Ability to work well with all types of providers/customers
• Sensitivity to the needs of every individual to be treated with respect and fairness
• Able to work well with others in a collaborative and respectful manner.
• Able to multi-task, deal with complexity on a frequent basis.
• Essential to perform all functions of the job accurately and in a timely manner.
• Able to work under pressure and time constraints.
• Able to arrive for work on time and maintain a good attendance record.
• Ability to maintain a professional demeanor and confidentiality
  

Sensory / Physical / Mental Requirements

Sensory:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical:

• Extended periods of sitting, computer use, talking and possibly standing.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

Mental:

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities.
• Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Candidates whose disabilities make them unable to meet these requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Work Environment

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

Protected Health Information (PHI) Access

Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role. All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164. In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community Health Plan policies can be cause for termination.

PHI is defined at 164.103 as:

"Protected health information means the individually identifiable health information that is

• Transmitted by electronic media
• Maintained in electronic media
• Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.
Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:

• Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
• Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
• That identifies the individual; or
• With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:

• Frequent - The position has frequent and/or daily access and responsibility for PHI. Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.