Utilization Review Nurse
Description
Job Description
Requirements
Job Description
- Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures
- Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
- Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits
- Conducts initial benefit determination reviews
- Consults with UM Medical Director to review requests that do not meet medical necessity
- Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Generates appropriate written correspondence to providers and/or members in accordance with UM policies and procedures
- Adheres to company policies and procedures regarding confidentiality and privacy
Requirements
- Must have valid PHRN (License)
- USRN license is a plus
- Minimum of 1-2years experience in Utilization Management
- Experience utilizing UM criteria including MCG or InterQual
- Minimum of three (2) years clinical nursing experience in an ambulatory or hospital setting
- Proficient computer skills and experience with Microsoft web based applications
- Experience in managed care and health insurance required
- Ability to communicate effectively verbally and in writing in English
- Ability to work holiday and weekend rotation
-
Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Hospitals and Health Care
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