Utilization Review Nurse

Job Description:
Olympic Health Management

Utilization Review Nurse

Summary: Provides medical, utilization, and claims processing experience necessary to evaluate the necessity, appropriateness and efficiency of medical services, procedures and facilities concerning the use of non-network facilities for Medicare SELECT Supplement policies.

Duties and Responsibilities:

1. Pre-Authorization Requests and Reconsideration Requests:
* Assist Customer Service with inquiries.
* Obtain additional information from health care providers, network facilities, policyholders and/or other parties.
* Provide individual research into insurer, policy, plan, and network facility.
* Work with healthcare providers and policyholders to steer services to network facilities.
* Determine if request qualifies as an exception to the network restrictions.
* Effectively and professionally communicate findings, outcomes, trends and decisions to appropriate parties through written correspondence or via telephone.
* Provide training and consistent support to Customer Service Representatives and Claims personnel.
* Educates healthcare providers concerning SELECT products.
* Assists policyholders in optimizing their contract benefits while adhering to specific policy network restrictions and exceptions.
* Research various disease processes, procedures, physician specialties, and facilities.
* Create and update related Department Policy and Procedure documents.
* Develop training materials for utilization in training and cross-training HLA staff.

2. Case Management:
* Identify potential cases, research history, calculate bed day usage, monitor status, communicate with health care professionals, facilitate network facility usage, investigate alternative level of care, maximize Medicare Part A bed days, generate reports and correspondence, and negotiate rates.

3. Claims Adjudication:
* Research and process claims pended on specialized adjudication screens.

4. Other related duties as assigned.
Knowledge, Skills and Abilities:
* Solid Utilization Review and/or Case Management background
* Strong verbal and written communication skills
* Working knowledge of medical terminology, anatomy and physiology, disease and pathology
* Working knowledge of medical claims, claim coding and payment methodologies
* Working knowledge of Medicare rules and regulations affecting payment for health services to Medicare beneficiaries.
* Proficiency with personal computers, including MS Word, Destiny and Excel
* Well developed organizational and time management skills
* Ability to work independently and in a team setting
* Ability to work well under various stressful and time sensitive situations
* Ability to maintain a sense of professionalism at all times
* Maintain confidentiality of member, physician and employee information.
* Willingness to support and educate co-workers, fostering a team-work atmosphere
Education and Experience:
* Registered Nurse or Licensed Practical Nurse licensed in Washington State
* Five (5) years of nursing experience
* Minimum three (3) additional experience in the health insurance industry and/or Utilization Review/Utilization Management field.

Essential Functions:
* Manual dexterity in hands to do extensive keyboarding
* Requires the ability to sit for extended periods of time
* Requires the ability to speak and hear to exchange information with customers on the telephone

HOW TO APPLY

1. Apply online by locating ? Click here to apply via the Aon Career Opportunity Portal? at the bottom of this job description.

OR

2. Visit our website: : www.ohmsystems.com and click on the ?CAREERS? link to download an application. Applications and job descriptions are also available at our office location: 2219 Rimland Dr., Bellingham, WA 98226

Olympic Health Management is an Equal Opportunity Employer, committed to a diverse workforce, M/F/D/V. Employment contingent on successful background check.



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