Posted on: March 16, 2023
- 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
- 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
- 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
- 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
- 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
- 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
- Collaborates with all levels of management as well as with
Medical Directors on complex inpatient admissions or
- Provides support to the unit Supervisor on special case reviews
- Performs all other miscellaneous responsibilities and duties as
assigned or directed.
Keywords: HMSA, Honolulu , Nurse Coordinator, Healthcare , Honolulu, Hawaii
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