Nurse Coordinator

Company: HMSA
Location: Honolulu
Posted on: March 16, 2023

Job Description:

• Oversees and coordinates SNF preauthorization, concurrent reviews, out of state reviews, and suspended claim reviews with the nurse reviewers. Manages the workload to guarantee review activities are performed accurately and timely according to accreditation guidelines.
  
• Conducts quarterly quality review audits to ensure accuracy of medical review decisions, timeliness, and reliability by the nurse reviewers. Applies clinical expertise, HMSA and applicable line of business policy criteria, nationally recognized clinical review criteria, and knowledge of standard practice to determine the appropriateness of determinations. Meets with nurse reviewers to review inconsistencies/discrepancies and to develop corrective action plans as needed. Findings are reported to the Facility Utilization Review Supervisor for further action and follow up.
  
• Develops workflows and assessment tools to ensure accuracy and consistency among review determinations. Assists in the development of policies and procedures in relation to review activities.
  
• Ensures all nurse reviewers are informed of and understand new review activities, policies and procedures, workflows, assessment tools, projects and review criteria. Trains all new nurse reviewers on review processes, criteria and accreditation guidelines.
  
• Communicates timely, accurate information, either verbally or in writing using discretion and judgment to the provider, suppliers and others as appropriate.
  
• Serves as liaison for internal departments as well as external customers such as community providers, suppliers and professional organizations.
  
• Provides back-up in daily review activities in the event of staff absences or high volume case referrals.
  
• Audits provider and member denial letters to ensure denial, benefit, and appeal language are accurate and consistent. Educate providers and vendors on clinical review determinations, policies, criteria and benefits as needed.
  
• Coordinates the Inter-Rater Reliability audits for the Facility Utilization Review Unit to ensure that medical review decisions are appropriate and consistent. Inconsistencies/discrepancies are discussed with the Medical Directors to resolve discrepancies. Reviews audit findings with the unit Supervisor to discuss and implement improvements.
  
• Collaborates with all levels of management as well as with Medical Directors on complex inpatient admissions or reviews.
  
• Provides support to the unit Supervisor on special case reviews and projects.
  
• Performs all other miscellaneous responsibilities and duties as assigned or directed.
  
  
  #LI-Hybrid

Keywords: HMSA, Honolulu , Nurse Coordinator, Healthcare , Honolulu, Hawaii