Utilization Review Nurse

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