UM Nurse Reviewer at Cognizant in Tampa, Florida

Job Description:

Summary:

The WCUM Nurse evaluates the appropriateness and necessity of medical treatment through the Utilization Management review process in order to promote quality, outcome based medical care while providing world-class service to customers in an accurate, efficient and courteous manner.

Responsibilities:

• Job holder will work with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks


• Performs Workers’ Compensation Utilization Management reviews in accordance with federal and state mandated regulations. Maintains compliance with regulatory changes affecting utilization management.


• Perform WCUM reviews (prospective/concurrent/retrospective) for inpatient/ outpatient services according to the URAC standards and client requirements and/or policies.


• Reviews WCUM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer.


• Adheres to Department of Labor, state and company WCUM timeframe requirements.


• Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.


• Tracks status of all utilization management reviews in progress.


• Communicates with claims adjusters and/or providers on requests that needs verification.


• Releases WCUM determinations to claim stakeholders following client-established protocols.


• Works closely with management team in the ongoing development and implementation of utilization management programs.


• Certifies reviews that meet clinical review criteria/guidelines.


• Adheres to quality standards and state UM guidelines.


• Maintains all required utilization management review documentation in the UM software in a timely manner.


• Serves as first level contact for customer complaint resolution.


• Responds to inbound telephone calls pertaining to WCUM reviews in a timely manner,

following client-established protocols.

• Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.


• Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.


• Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.


• Perform assigned tasks or work queues to assure cases are handled timely as well as meet established timelines for urgent requests.


• Adheres to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established best practice WCUM time frames, as appropriate.


• Manages assigned workload within established performance standards.


• Maintain confidentiality of all information, policies, and procedures as required by the


• Health Insurance Portability and Accountability Act (HIPAA) protocols.


• Adhere to program quality standards and maintain acceptable levels of performance, including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.


• Learn new methods and services as the job requires.

• Advise WCUM Nurse Team Lead and/or WCUM Intake SME of any potential problems as they become evident.


• Attend meetings to achieve departmental goals and objectives.


• Perform other duties as assigned or required.

Minimum Qualifications:

• Must have a Bachelor’s Degree in Nursing with an active and unrestricted license to practice in at least one (1) year of clinical experience is preferred.


• Knowledge of nursing principles, techniques, and procedures for the care of patients.


• Knowledge of medical terminology, anatomy, physiology and concepts of disease.


• Makes sound clinical decisions in a timely manner.


• Knowledge of basic ICD-9 or ICD 10, and CPT Coding is preferred.


• Knowledge on federal, state, URAC, and client protocols is preferred.


• Able to multi-task and prioritize assignments.


• Work on projects and meet deadlines.


• Skill in providing effective nursing care, assessing patient situations and taking effective courses of action.


• Detail oriented, with good organizational skills.


• Good critical and analytical thinking skills.


• Effectively meets strict deadlines.

Domain Skills

* Proficiency Legends