Under the general supervision of the Inpatient Services Manager, the Concurrent Review Nurse is responsible for ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient precertification and prior authorization of services by utilizing applicable medical policy, evidenced based industry standards and managed care products.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Develops, educates, and manages clinical and non-clinical staff within the guidelines of Leon.
- Health’s policies and procedures to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently.
- Is responsible for monitoring incoming calls and written inquiries from members, providers, and inhouse departments.
- Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization reviews
- Is responsible for the data entry of service requests/decisions into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies.
- Reviews clinical documentation for pre-certifications and continued (concurrent) reviews prior tothe review.
- Conducts on site and/or telephonic reviews for appropriateness of treatment setting on inpatient/outpatient admissions and continued (concurrent) stays utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
- Conducts Medical and BH reviews prior and post authorization service requests utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products.
- Provides authorization to providers, facilities, and members (when applicable) for inpatient admission, outpatient precertification, prior authorization, and post service requests.
- Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate.
- Provides complete and accurate documentation specifying rational for approvals.
- Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.
- Updates census reports, notes, and all authorization documentation daily including running a daily admissions and discharge report.
EDUCATION
Bachelor degree in Nursing
WORK EXPERIENCE
Minimum of two (2) years of experience in clinical reviews
LANGUAGE SKILLS
Bilingual English/Spanish fluency.
What We Do
Medicare Advantage Plan Founded and led by the LEON family, with the commitment of improving the lives and health of all members.
