Retro Review Nurse (RN OR LVN)
Orange, CA 92856
The Retro Review Nurse is responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for all plan members. The Nurse works in collaboration with providers, Regional and Sr Medical Directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient.
(May include but are not limited to)
- Review retrospective requests for emergency services, medical necessity and refer to Medical Director any referral that requires additional expertise.
- Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals
- Utilize Milliman Guidelines to assist in determinations of referrals.
- Knowledge of CMS chapter 13
- Maintain goals for established turn-around time (TAT) for referral processing.
- Initiate single service agreements (SSA) when services required are not available in network.
- Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
- Monitor Fax Folders, System Queues and Email for incoming requests.
- Verify eligibility and/or benefit coverage for requested services.
- Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
- Contact requesting provider and request medical records, orders, and/or necessary documentation in order to process related pre-service requests/authorizations when necessary.
- Accurately documents referral process and any pertinent determination factors within the referral system.
- Review referral denials for appropriate guidelines and language.
- Assist Medical Directors in reviewing and responding to Appeals and Grievances
- Contact members and maintain documentation of call for Expedited requests.
- Assist with UM queue calls relating to UM review and pre-service status when needed.
- Recognize work-related problems and contributes to solutions.
- Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
- Maintain confidentiality of information between and among health care professionals.
- Other duties as assigned by UM Manager.
- Minimum Experience:
- At least 2 years' experience with Medicaid and/or Medicare. 1-2 years' experience in a medical setting working with IPAs, entering referrals/prior authorizations. Must of have knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
- A minimum of five years of relevant professional experience.
- Knowledgeable with CMS guidelines and regulations.
- Experience with the application of clinical criteria (i.e., Milliman, Interqual, Apollo, CMS National and Local Coverage Determinations, etc.)
- RN with clinical experience.
- Current, Active and Unrestricted California Registered Nursing license; CPHQ or ABQAURP, or Six Sigma certification preferred.
- Minimum Associate's degree, Bachelor's degree preferred.
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook
- Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
- Bilingual (English/Spanish) preferred
- Positive, team player attitude
- Excellent relationship management skills
Skills and Abilities
- Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
- Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
- Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution;
- Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
- Report Analysis Skills: Comprehend and analyze statistical reports.
- Transplant knowledge a plus
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.