RN Nurse Reviewer

CSTS Customer Service and Technology Solutions LLC is a dedicated third-party administrator specializing in managing essential operational functions for insurance plans. Our focus is on streamlining processes such as claims processing, customer enrollment, premium collection, and ensuring compliance with federal regulations. We are passionate about transforming the healthcare experience by delivering outstanding products and services to our partner

CSTS is looking for a RN Nurse Reviewer to perform utilization management activities in accordance with all CMS federal and local guidelines as well as ACHA and NCQA guidelines and regulations. The Nurse Reviewer reviews specific prior authorization requests against regulatory guidelines and evidence-based criteria. The Nurse Reviewer approves cases that do meet criteria and refers cases that do not meet criteria, in whole or in part, to the UM Medical Director for a determination.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Duties and Responsibilities:

Responsible for the daily operational duties including, but not limited to:

• Participates in the review process, including preservice and retrospective reviews (Part B) according to specific chosen criteria such as, but not limited to CMS’ national and local coverage determinations (NDCs/LCDs) and Health Plan coverage guidelines, for approval or referral to Director of Utilization Management.
• Reviews the Prior Authorization Listing (PAL) and assists with periodic revisions with the Director of UM.
• Ensures cases are referred to the UM Medical Director when the treatment request does not meet medical necessity guidelines in whole or in part, or when a peer-to-peer conversation is necessary to establish appropriateness.
• Ensures referrals to the UM Medical Director(s) are made in a timely manner, allowing the physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within state and federal guidelines or NCQA mandated turnaround times.
• Communicates with members of the treatment team when necessary.
• Assists with the reviews of medical records, using clinical expertise and compares information to established guidelines, Health Plan coverage guidelines, NCDs/LCDs and the member’s benefit plan.
• Participates in orientation and departmental training programs.
• Acts as a training mentor, if selected by the Director of UM.
• Relies on clinical support from Director of UM. Discusses cases and accesses the Director of UM electronically or telephonically whenever necessary.
• Completes Inter-Rater Reliability (IRR) at least annually to staff.
• Provides consistency in UM decisions.
• Adheres to all confidentiality, PHI, HIPAA and privacy requirements.
• Identifies and refers high-risk/high-cost patients for possible case management intervention and identifies patients with chronic disease processes for possible disease management intervention.
• Assists in coordination and the delivery of cost-effective, quality-based health care services for health plan members.
• Coordinates with providers of medical services and equipment to facilitate effective communication, referrals, and alternative treatment plan development.
• Outreaches for relevant information if not present and documents same in Contacts section in the UM system.
• Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care in accordance with established policy.
• Supports the organization’s Quality Management Program; participates in ongoing clinical quality improvement activities as it relates to internal programs and processes, studies, projects or medical record review as directed by the Director of UM.
• Addresses the needs of internal and external customers, including co-workers, internal departments, Members, providers, and vendors.
• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
• Attends workshops and seminars to improve knowledge.
• Participates in various task force and committee projects, as requested.
• Other duties as assigned by the Director of UM.

Other Requirements: Perform on call duties on the weekends and holidays as assigned by the Director of UM. Actively participate in internal and external meetings as requested.

Education and Experience:

RN with state license in good standing with experience in Utilization Management prior authorization and concurrent review.

Language Ability: Proficient in English, clear speaking ability, bilingual preferred.

Computer Skills: 40 WPM in typing, proficiency in MS Office including Outlook, Excel and Word. Experience with Case Management software including InterQual® Care Enhance Review Manager Enterprise (CERME) preferred. High level of computer proficiency required.

Work Environment:

Ability to work independently in an office environment without distractions. Must be able to work collaboratively with all members of the utilization management team and medical director.

Physical Demands:

The employee must have close vision ability, and be able to use the telephone and the computer extensively during the work day. While performing the duties of this job the employee is regularly required to sit, stand, use hands and arms, talk, and hear.

CSTS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All employment decisions are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion, sex (including pregnancy and gender identity), sexual orientation, national origin, age, disability, genetic information, or veteran status.

Pay: $74,000.00 per year

Experience:

• Managed Care: 1 year (Required)
• Utilization review: 1 year (Required)

Work Location: In person

Salary : $74,000