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DATE ADDED: Thu 27/09/2018

Utilization Review Nurse (LPN) (BHJOB1435_22934)

Richmond, USA
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COMPANY: ASTYRA CORPORATION

Job Description

Start Date: November 05, 2018 (long term contract)

Hours: 8 AM - 5 PM Monday - Friday

The Clinical Reviewer will independently and in a team environment to review/audit medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision making to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.

Essential Functions:

  • Utilizing healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with contract requirements
  • Documenting and reporting findings of reviews and audits in accordance with professional standards and project protocols
  • Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
  • Interpreting and analyzing health care data
  • Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
  • Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
  • Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
  • Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
  • Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
  • Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Client policies, procedures and guidelines
  • Maintaining security of and confidentiality of all protected health information (PHI)
  • Participating in and contributing to quality management systems
  • Additional responsibilities as assigned

Requirements:

  • Must have 2 years Prior Authorization or Utilization Review experience
  • Minimum of two years of clinical experience in an acute or med-surgical environment required
  • Minimum of one-year UR and/or Prior Authorization or related experience.
  • Knowledge of InterQual criteria strongly preferred
  • Knowledge of current NCQA/URAC standards strongly preferred
  • Knowledge of the organization of medical records, medical terminology, and disease process required.
  • Experience in quality improvement projects desired
  • Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
  • Strong analytical and problem-solving skills
  • Excellent communication skills including written and verbal
  • Self-directed and motivated, with ability to work independently under general instructions
  • Ability to work in a team environment and manage multiple deadlines and prioritize assignments
  • Well organized with a high degree of accuracy and attention to detail
  • Not currently sanctioned or excluded from any program operated by federal or state agencies including Medicare and Medicaid

Education/Certifications

  • Current licensed practical nurse (LPN) license in good standing
  • Graduation from an accredited LPN program

Company Description
Astyra Corporation is a staffing and consulting company that is locally owned and operated right here in the heart of RVA. Astyra offers a unique approach to solving the business challenges of its clients. After being in business for over 20 years, we have evolved and grown - smart ideas, ingenuity and never settling for failure are our hallmark traits. We are locals with a national presence and need a like-minded; client focused professional who wants to make a difference every day.


Role: Utilization Review Nurse (LPN) (BHJOB1435_22934)
Job Type:
Location: Richmond,

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