The Utilization Review Nurse will perform retrospective clinical reviews of inpatient medical and psychiatric hospitalizations for Medicaid and CHIP beneficiaries. This includes reviewing approximately 200 medical and 10 psychiatric hospitalization cases per month to ensure appropriate utilization, DRG assignment, and quality of care in alignment with DSS and CMS policies.

Key Responsibilities:

• Conduct retrospective utilization reviews, including admission, discharge, DRG validation, length of stay, and quality of care analysis.
• Perform peer reviews for both DRG and non-DRG admissions, including psychiatric cases.
• Document findings and submit comprehensive reports and notifications to DSS, hospitals, and physicians as appropriate.
• Handle reconsideration reviews initiated by recipients or providers.
• Collaborate with DSS to establish reporting best practices and submit required documentation monthly.
• Acquire and securely manage medical records requested for supplemental review.
• Ensure reviews are completed within 60 days, or within 6 months under special circumstances.

Minimum Qualifications:

• In-depth knowledge of DRG systems, hospital admission criteria, and Medicaid utilization review protocols.
• Excellent documentation and critical thinking skills.
• Comfortable working with regulatory guidelines, including CMS Internet-Only Manuals.
• Prior certification as part of a QIO or experience working in a QIO-like setting.
• Behavioral health review experience, especially psychiatric inpatient.
• Knowledge of South Dakota Medicaid programs and reimbursement methodologies.