Summary: The UM Reviewer serves as a contact and resource person to Health Solutions’ members for the utilization review (UR) of healthcare services. The UM Reviewer will be responsible for complying with utilization review procedures in accordance with Texas UR Certification requirements, as well as carrying out day today pre-authorization functions. The Utilization Review Nurse will also be responsible for issuing pre-authorization approvals/denials, notifying providers/enrollees of denials verbally and in writing. They will also coordinate pending cases for a review determination with Health Solutions Medical Director, coordinate pre-authorization activities with affiliated health plans and interface with network physician office staff when benefit coverage or UR questions or issues arise. To support care management initiatives, the UM Reviewer should also identify enrollees in need of case/disease management services so that proactive interventions can occur. Essential Duties and Responsibilities: Serves as a resource to the Claims Department in determining the medical necessity of claims submitted by network physicians according to Health Solutions payor’s prospective review criteria and authorization procedures. Coordinates pre-certification activities with contracted health plans and interfaces with providers and/or enrollees when pre-certification issues arise. Educates and affords training to network physicians/office staff on prospective review/precertification requirements. Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to support care management initiatives and sound decision-making for review determinations. Utilizes InterQual, Milliman and other Medical Management/health plan endorsed or developed criteria when evaluating cases for pre-authorization; considers special needs and other unique medical needs of enrollees as part of the evaluation process Provides direction and answers phone inquiries from providers and enrollees regarding Health Solutions’ pre-authorization program. Routes provider related UM complaints to the correct department for documentation and investigation when calls are received directly from providers or enrollees. Conducts timely medical necessity reviews of all covered services in accordance with TDI, CMS and other regulatory bodies and adheres to required timelines. Establishes/maintains a good rapport with providers to obtain information necessary for review determinations. Present all cases that do not meet clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination. Collect accurate data for system input by using correct coding of diagnoses and/or procedures and utilizing complete and concise documentation of all pertinent information obtained. Assists the Director and Medical Director in identifying additional guidelines or protocols needing either development or refinement in order to support an efficient, effective and quality-oriented pre-authorization process Serves as a liaison with participating hospitals' Case Management staff in order to be apprised of inpatient admission status and care management needs; serves as a resource to the hospital staff by assisting in alternative care placements incompliance to the applicable managed care plan or certified workers’ compensation network benefit coverage requirements Identifies enrollees in need of case/disease management services and makes referrals to Case Management staff Follows other procedures to make appropriate referrals relative to individual cases (Case management, Stop Loss, etc.) Educates providers and other physicians about the Health Solutions case management referral program as potential enrollees are identified via the pre-authorization process. Identifies potential quality of care issues as relates to data collected as part of the preauthorization process; flags cases for review by the Appeals & Outcomes Coordinator Reports potential risk management cases or situations to the Medical Management Manger/Director for immediate intervention or investigation. Tracks enrollee cases for prospective QI study or as needed for reporting, as maybe delegated by the Quality & Outcomes Coordinator. Adheres to and apply all Health Solutions policies, procedures, and guidelines appropriately. Attends all in-service and trainings as required Processes and maintain confidential information according to confidentiality policy. Performs other related duties as requested by Supervisor, Manager, or Director. Achieves an in-depth knowledge of client benefit plans. Maintains a 90% or greater score on the quarterly audit tool and IRR testing Communicate, collaborate and cooperate with internal and external stakeholders. Adheres to all Compliance/Program Integrity requirements. Complies with HIPAA Regulations. Adheres to all company policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity and quality of service. Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff. Education/Licenses/Certifications: Graduate of an accredited school of nursing (Associates of Nursing or Bachelor of Nursing) Licenses/Certifications: Current, unrestricted Texas licensure to practice as a Registered Nurse or Licensed Vocational Nurse required and current unrestricted Certification in Utilization Review/Utilization Management preferred Qualifications: One (1) to two (2) years’ experience in a Managed Care environment performing preauthorization, concurrent review or case management Knowledgeable and compliant with all relevant laws, rules, regulations and accreditation standards and requirements Strong clinical background in nursing Knowledge of insurance terminology Basic knowledge of computer systems Excellent verbal and written communication skills Ability to perform multiple tasks simultaneously, work under pressure, and meet critical deadlines Excellent typing skills Ability to understand and recognize ICD-9/CPT/HCPC coding Ability to work independently, manage time and prioritize projects. * Note, there are weekends/holidays included in the schedule ABOUT APEX HEALTH SOLUTIONS Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.