Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Utilization Review Nurse works as a member of the Utilization Review Team and is responsible for reviewing claims disputes and retrospective requests for services requiring clinical review prior to payment.

The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to identify gaps in billing and coding between claims and authorizations, ensure members receive appropriate levels of care, while promoting cost effective medical outcomes.

Job Description

Key Outcomes/Results:

• Manages the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance, or reimbursement related issues. Responsible for leveraging clinical and/or coding experience to perform facility and provider medical records reviews for claims dispute decisions.

• Utilizes evidence-based criteria, clinical data, coding guidelines, medical information, benefit plans and policies, CMS criteria, NCD/LCDs, Tricare policies, and NCQA standards to support accurate medical necessity and dispute decisions.

• Partners with Medical Directors, Utilization Review Team, Provider Inquiry, and Claims regarding issues and trends.

• Identifies and refers cases to compliance for possible fraudulent issues.

• Reviews Continuity of Care cases.

• Coordinates referrals to Care Management, as appropriate.

• As needed, may also review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.

• Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.

• Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.

• Participates as a member of an interdisciplinary team in the Health Management Department.

• Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time.

• Mentors new staff as assigned.

• Maintains quality audit scores within department standards.

• Maintains productivity within department standards.

• Assists in creation and updating of department policies and procedures.

• Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings. Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.

• Demonstrates flexibility and agility in working in a fast paced, team-oriented environment, able to multi-task from one case type to another.

• Assumes extra duties as assigned based on business needs.

Education/Experience:

• 3+ years of clinical nursing experience as a RN, with a focus of Utilization Management in a managed care environment.

• Medicare experience required.

• Coding and appeals experience required.

• Associate degree required; BSN preferred

Required License(s) and/or Certification(s):

• Unrestricted state license as a Registered Nurse

• Certification in managed care nursing or care management desired (CMCN or CCM)

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values.

• Maintains current licensure and practices within scope of license for current state of residence.

• Maintains knowledge of Scope of Nursing Practice in states where licensed.

• Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately.

• Ability to analyze data metrics, outcomes, and trends.

• Excellent interpersonal, verbal, and written communication skills.

• Critical thinking: can identify root causes and understands coordination of medical and clinical information.

• Ability to prioritize time and tasks efficiently and effectively.

• Ability to manage multiple demands.

• Ability to function independently.

• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit https://careers.martinspoint.org .