Precertification Registered Nurse

Description:

The Precertification Nurse position is responsible for conducting medical necessity review activities in accordance with Veracity Benefits policies and procedures. The position responsibilities include the review of inpatient and outpatient services for medical necessity utilizing clinical criteria guidelines, coordinating with provider offices to receive the needed documentation for review of services, and the coordination with the Care Management department for those members with acute, complex needs

• Medical necessity review of inpatient and outpatient services using approved clinical criterial guidelines.
• Collaboration and communication with providers regarding the status of their request.
• Identification of those patients/members who require assistance with facilitation of discharge planning and referral to appropriate parties and/or programs as necessary.
• Timely review of requests for providers to continue with the member treatment plan.
• Analysis of the place of care to determine if member is going to the most appropriate, cost-effective facility and referral to outreach staff to assist that member in discussing alternative treatment locations as needed.
• Identifies and communicates high-cost claimants to the appropriate points of contact.Coordinates access to providers, community resources, and health benefits as necessary.
• Accurately and clearly documents precertification activities included but not limited to review of medical records, use of clinical criteria guidelines, verbal communication with providers/facilities, outgoing communication including faxes & emails, incoming communication, referral of cases to internal and external vendors/programs, identification of high-cost cases.
• Advocate for appropriate level of care when required.
• Engages Medical Director or other designated supervisory physician for consultations when appropriate.
• Refers cases for MD review when clinical criteria guidelines are not being met.
• Coordinates appeal when requested.
• Communicates with Medical Director or Physician Advisor or appropriate leadership personnel when there is a threat to patient safety.
• Participates in regular clinical rounds, staff meetings, and committee meetings.
• Participates in providing feedback and input into precertification program services, procedures, and resource needs.
• Advocates on behalf of the member to secure access to quality, cost-effective care and attainment of treatment goals.
• Maintains confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Requirements:

• Registered Nurse with a clear, active and unrestricted license in state of residence
• Multi-state Compact RN license preferred (required upon hire)
• Associates Degree in health-related field
• A Bachelors (or higher) degree in a health-related field preferred
• Minimum of five (5) years direct patient care experience in an acute care or hospital-based setting
• Three (3) to five (5) years of utilization management or related experience preferred
• Experience working in a managed care setting preferred
• Strong Problem-solving skills are essential
• Excellent typing, computer and documentation skills
• Ability to coordinate and communicate with a multidisciplinary team (internal and external)

About OneVeracity
OneVeracity partners with brokers to help self-funded employers reduce medical and pharmacy costs without compromising care. It delivers Health Plan Solutions, VeracityRx, Care Solutions, and Onsite Health Centers in one integrated model that gives employers a clearer, more coordinated way to manage healthcare spend. The approach is grounded in three guiding principles: enhance care, reduce costs, and make it easy. Founded in 2019 and headquartered in Kennesaw, Georgia, OneVeracity is a privately held company that serves self-funded employers across industries including manufacturing, government, and professional services. Learn more at www.OneVeracity.com.