Utilization Review Nurse (RN) - Managed Care
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.) license.
CPUM/CPUR or CPHM (or similar) certification is preferred
2 years acute care clinical nursing experience, to include working with transplant patients/members is required.
At least 3 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 MCG (Milliman Care Guidelines) 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.