<p><strong>Company Description</strong></p><p>ProviDRs Care operates a PPO network serving multiple states nationwide. The company focuses on enhancing the healthcare experience for both employers and providers through effective solutions. The organization and its staff actively participate in various professional and industry groups, demonstrating a commitment to excellence and community involvement.</p><p><br></p><p><strong>Role Description</strong></p><p>This is a part-time role transitioning to a full-time, on-site role based in Wichita, KS, for a Utilization Review Nurse. The Utilization Review Nurse will be responsible for conducting utilization management reviews, creating discharge plans, and ensuring coordination of care. Duties also include evaluating medical records, collaborating with healthcare providers, and supporting adherence to standards of medical care. This role involves making determinations about medical necessity, treatment appropriateness, and level of care.</p><p><br></p><p><strong>Key Responsibilities</strong></p><p><strong>Utilization Review</strong></p><ul><li>Conduct initial pre-authorization, concurrent, and retrospective reviews for medical necessity, appropriateness, and efficiency of services for services provided across various settings, including acute care, skilled nursing facilities, outpatient clinics, and home health.</li><li>Use industry-standard guidelines (e.g., Milliman Care Guidelines [MCG], InterQual) to assess the necessity and duration of services.</li><li>Make recommendations regarding care delivery to align with medical necessity and insurance requirements.</li><li>Make determinations on service approvals or escalations to Medical Directors for review.</li></ul><p><br></p><p><strong>Care Coordination</strong></p><ul><li>Evaluate medical records, physician orders, and care plans to ensure treatments align with evidence-based guidelines.</li><li>Identify and recommend the most appropriate care settings (e.g., inpatient, outpatient, observation) based on clinical findings and insurance criteria. </li><li>Collaborate with providers, case managers, and members to ensure seamless transitions of care and develop discharge plans that ensure continuity of care and prevent readmissions. </li><li>Facilitate referrals for specialized care, diagnostic services, or alternative treatment options when necessary.</li><li>Provide education to members and providers about plan benefits and covered services.</li></ul><p><br></p><p><strong>Insurance Authorization and Appeals</strong></p><ul><li>Analyze and evaluate medical records, treatment plans, and physician recommendations to determine if a procedure, medication, or service meets insurance criteria.</li><li>Collaborate with physicians, healthcare providers, and insurance companies to gather necessary information and clarify treatment plans.</li><li>Ensure that requested services align with payer policies, clinical guidelines, and evidence-based practices. </li><li>Review insurance denial letters to understand the reason for denial and assess whether the treatment is medically necessary. </li><li>Prepare and present appeals for denied services by collecting and organizing medical records, provider notes, and other documents to support appeal cases. </li><li>Draft detailed, clinically supported appeal letters to insurance companies, clearly explaining the necessity of the denied service.</li><li>Assists with peer-to-peer reviews to support authorization requests.</li></ul><p><br></p><p><strong>Documentation and Reporting</strong></p><ul><li>Maintain accurate and detailed records of all reviews, communications, and decisions in compliance with regulatory standards and internal policies.</li><li>Monitor and report trends in care delivery, authorization denials, and utilization patterns to identify opportunities for process improvement.</li><li>Assist with the preparation of reports and summaries for clients and carriers.</li><li>Assist in the preparation of reporting for stop-loss renewal and work with stop-loss carriers to answer their questions.</li></ul><p><br></p><p><strong>Regulatory Compliance</strong></p><ul><li>Ensure adherence to state, federal, and accreditation requirements (e.g., URAC, NCQA).</li><li>Stay updated on industry standards, clinical guidelines, and health plan policies.</li><li>Participate in continuing education programs related to utilization management, payer regulations, and clinical guidelines.</li><li>Stay informed about changes in diagnostic and procedural coding standards, such as updates to ICD-10, CPT, and HCPCS codes.</li></ul><p><br></p><p><strong>Team Collaboration</strong></p><ul><li>Work closely with the Medical Management team to optimize processes and improve outcomes.</li><li>Participate in interdisciplinary meetings, training sessions, and policy reviews.</li><li>Work with Director of Integrated Health Management, Case Manager, Care Navigator, and member concierge team</li></ul><p><br></p><p><strong>Qualifications</strong></p><ul><li>Proficiency in Utilization Management and Discharge Planning</li><li>Strong background in Medicine and Nursing</li><li>Experience with reviewing and analyzing Medical Records</li><li>Excellent communication and collaboration skills to work with healthcare providers</li><li>Active and unencumbered Registered Nurse (RN) license in Kansas</li><li>Knowledge of healthcare policies, procedures, and compliance standards</li><li>Bachelor's degree in nursing (BSN) preferred</li><li>Minimum of 3 years of clinical nursing experience, preferably in case management, utilization review, or managed care settings.</li><li>Familiarity with payer requirements, authorization process, clinical criteria, and healthcare delivery systems</li></ul>
