Utilization Clinical Reviewer

Job Summary

The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.

Education & Experience

Required:

• Active, unrestricted RN license
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2+ years clinical experience
• 2+ years UM experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
• Demonstrates effective verbal and written communication skills

Preferred:

• 3+ years Medical / Surgical experience
• Behavioral Health experience
• 1 year TriWest or TRICARE experience
• Managed Care experience

Key Responsibilities

• Conducts prior authorization, continued stay, and referral management activities.
• Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
• Interprets information and makes decision whether authorizations align with the TriWest benefit program.
• Ensures timely reviews for requesting facilities and appropriate notification to parties.
• Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
• Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
• Prepares cases for Medical Director and Peer Review according to established policy.
• Refers potential quality issues and complaints to Clinical Quality Management.
• Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
• Maintain compliance with Federal, State and accreditation organizations.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.

Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment

Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding

Working Conditions

Working Conditions:

• Ability to cover any work shift
• Ability to work overtime, if needed
• Onsite: Works within a standard office environment
• Remote: Private and secure work space and work station with high speed internet is required.
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $86,000 to $95,000 per year.