Utilization Review Nurse

Location: San Diego, CA
Date Posted: 04-13-2018
CareNational
Utilization Review Nurse (RN or LVN) - Managed Care
San Diego, CA
 
* Offers variable mix of telephonic & field Utilization Review, traveling between a home-office & area provider facilities *
** Great for nurses who love variety and area travel (around 40%-50%) - all mileage is reimbursed!! *
*

Utilization Review Nurse Job Summary:
 
  • The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
  • The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
  • Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
  • The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
 
Utilization Review Nurse Background:
 
  • Current, valid, and unrestricted state Registered Nurse (R.N.) or License Vocational Nurse (L.V.N.) license.
  • CCM or CPUR or similar certification is preferred
  • 2 years acute care clinical nursing experience is required.
  • 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
 
#CLINICAL
 
Mike Vega - CHP
Search Consultant

CareNational Healthcare Services
mike@carenational.com

480-264-0620 (CALL – TEXT – FAX)
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