Utilization Review RN
Company: Hines & Associates Inc
Location: Rockford
Posted on: September 23, 2024
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Job Description:
Description:Nurses - are you looking for a change? Want to work
no nights, no weekends, and no holidays? Be able to work from home
50% of the time once trained? Check out Hines & Associates! ABOUT
US:Hines is a nationwide, independent leader in personalized
managed health care, focused on what's important to
you-comprehensive services with the program excellence and cost
containment that you demand. Hines & Associates, Inc.'s reputation
as an industry leader is founded on over three decades of
innovative and professional health care excellence. Serving all
aspects of the industry, Hines is committed to conserving health
care dollars while ensuring quality care through effective programs
and personalized service.WHAT WE OFFER:Competitive salary and
benefits, including medical, dental, vision, long-term care,
short-term disability, long-term disability, and company paid life
insurance.401k plan with company match, fully vested after 1
year.No weekends and nights!Paid HolidaysWork-life
balance.Remote/hybrid setting (once trained)ROLE DESCRIPTION:This
individual will utilize clinical knowledge and communication skills
to obtain patient specific information regarding patient condition
and proposed treatments and procedures to determine if illness
and/or proposed services meet acceptable criteria sets and
acceptable nursing practice guidelines for outpatient treatment or
inpatient confinement. This individual will certify treatment for
confinement when criteria and/or practice guidelines are met, in
accordance with the health benefit plan, disability, workers
compensation regulations and state and federal regulations. If
these conditions do not appear to be met, this individual will
defer decision to a second level reviewer. This individual
interfaces with case managers and disease management nurses on
active cases involved in other Hines' programs.*****This is a
Monday through Friday position, 9:30 AM to 6:00
PM.******RESPONSIBILITIES AND PERFORMANCE:Completes first level
reviews within the scope of practice relevant to the clinical
area(s) addressed in the initial clinical review. General
Medical-Surgical nursing is sufficient to be relevant to the
clinical areas addressed in most initial clinical reviews.
.Demonstrates ability to assess a patient's current medical status,
including complications and untoward events, which may require
additional intervention. Provides certification of medical,
disability and workers compensation cases.Demonstrates a thorough
understanding of criteria sets and their limitations including when
a second level review is required.Evaluates appropriateness of
current plan of care.Assesses aftercare needs, implements discharge
planning and/or case management referral in a timely
manner.Maintains knowledge of current advances and trends in
medical care.Demonstrates knowledge of URAC guidelines, Hines
policies and procedures, and standards of practice and their
revisions. Able to attain and maintain the minimal quality
assurance performance standards.Demonstrates assertiveness in
completion of precertification and concurrent review within the
guidelines of URAC, disability, workers compensation regulations,
and state and federal requirements and according to the Hines
policies and procedures.Performs onsite evaluations as needed or
requested.Additional responsibilities as
assigned.COMMUNICATION:Communicates with hospital staff,
physicians, other providers and Hines customer contacts in a
competent, calm, effective and professional manner.Effectively
communicates the need to refer to a higher-level review for
questionable plans of treatment.Provides written documentation
concerning the clinical information obtained regarding the
patient's status, benefit and claim concerns, and validation of
criteria.Communicates knowledge of policies and procedures, URAC
guidelines, disability and workers compensation regulations, state
and federal requirements, and standards of practice.PERSONAL AND
PROFESSIONAL:Participates in self-evaluation by identifying areas
of strength and limitations and offers and accepts constructive
criticism.Creative and assertive.All First Level Reviewers are
required to sign and honor a confidentiality statement at the time
of hire and annually at the time of performance
reviews.PM21Requirements:QUALIFICATIONS:Registered Nurse with
valid, unrestricted, current nursing license in the state or
territory of the United States where employed. For mental
health/substance abuse, licensed medical professional with an
unrestricted license in the state or in a state that has licensure
reciprocation with the state of the office location the employee is
working in may perform first level reviews. Accepted licensure
includes but is not limited to RN, LMSW, LMHC.Successful completion
of UR nurse orientation program.Minimum of 3 years recent acute
clinical practice required, 5 years preferred.Managed care,
disability or workers compensation experience helpful but not
mandatory.Customer service
oriented.PI41cecdcd649b-25660-34548457
Keywords: Hines & Associates Inc, Rockford , Utilization Review RN, Healthcare , Rockford, Illinois
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