Utilization Management Nurse ACD

Profile

Description

Responsibilities

The Utilization Management Nurse 2 will be responsible for performing clinical audits on medical record documentation for quality and clinical compliance with contract requirements as outlined in the Autism Care Demonstration (ACD) policy, TRICARE Operations Manual (TOM) Chapter 18, Section 4. Reviews shall compare the beneficiaries' session notes to the provider's claims to determine whether all required documentation exists and is adequate to support the submitted charges. Comprehensive medical records review will be conducted on applied behavior analysis providers' claims for specified ABA CPT codes.

Our Department of Defense Contract requires U.S. citizenship for this position .

75% Quality Monitoring Audits.

Review and assess necessary record components.

Complete assigned audits timely and in accordance with contract requirements.

Maintain the web application tracking system to ensure all providers are in compliance based on the findings of their audits.

10% Assist with reviews from WPS, Prepayment Claim Reviews, Claims Oversight and other departments as needed.

10% Perform other duties as assigned by Supervisor, Manager and/or Director.

5% Utilizes established reporting and tracking tools to monitor audit outcomes and provider behavior.

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives .

Required Qualifications

Active R.N. license in the state(s) in which nurse is required to practice

Prior medical claim interpretation and processing experience

Working knowledge of ICD-9, HCPCS, DRG use

Minimum of three (3) years of clinical nursing experience

Minimum of one (1) year of prior experience in Behavioral Health or ABA therapy

Excellent written and oral communication skills

Knowledge of TRICARE Policy and Regulations

Proficient with Microsoft office products to include Word, Excel and Outlook

Our Department of Defense Contract requires U.S. citizenship for this position

Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

Work at Home/Remote Requirements

Must ensure designated work area is free from distractions during work hours and virtual meetings

Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Preferred Qualifications

Bachelor's degree in Nursing

MCG Criteria knowledge

Experience in TRICARE or other Federally regulated healthcare programs

Additional Information

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com