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
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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