Local Contract Nurse Level III RN - Utilization Review
Philadelphia, PA
Pyramid Consulting
5x8 hrs, Days

This position has potential to extend or convert into permanent and is fully Remote opportunity.

Key Responsibilities

• Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination.  Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
• Note:  InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making.
• Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
• Reviews treatment plans/plan of care with provider for requested services/procedures,  inpatient admissions or continued stay, clarifying medical information with provider if needed.
• Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination.
• Performs early identification of members to evaluate discharge planning needs.
• Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
• Reports potential utilization issues or trends to designated manager and recommendations for improvement.
• Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care.
• Appropriately refers cases to Case and Disease Management.
• Ensures request is covered within the member’s benefit plan.   
• Ensures utilization decisions are compliant with state, federal and accreditation regulations.
• Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
• Ensures that all key functions are documented via Care Management and Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.
• Performs additional duties assigned.