intus - Contract Utilization Management Nurse

• Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are: • Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions. • In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles. • Active involvement in various aspects of the utilization management process, including: • Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization. • Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care. • Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions. • Employ effective use of knowledge, critical thinking, and skills to: • Advocate quality care and enhanced quality of life • Advocate decreased hospital stay when appropriate • Maintain accurate records of all patient related interactions • Comprehensive review of provider network appeals. • Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies.