Nurse, Concurrent Review

 Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: 

 Admission reviews

 Continued stay reviews

 Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)

 Related follow-up activities and documentation updates

 Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions

 Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions

 Facilitates resolution of escalated cases that may require special handling

 Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines

 Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes

 Maintains written documentation according to HealthHelp’s documentation policy

 Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations

 Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs

 Complies with URAC & NCQA standards or other requisite regulating bodies

 Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management

 Keeps current with regulation changes as provided by Compliance Department and Nursing Management

 Functions as subject matter expert to support Compliance Department initiatives and updates

 Collects and enters confidential information ensuring the highest level of confidentiality in all areas

 Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times

 Maintains availability to support concurrent review coverage requirements, which may include non-standard  business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes

 Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines

 Appropriately identifies and refers quality issues to UM Leadership

 Collaborates with client personnel to resolve customer concerns

 Provides quality customer service through interaction with providers, administrative staff, and others

 Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others

 Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy

 Participates in the HealthHelp Quality Management Program, as required

 Performs other related duties and projects as assigned to meet business needs