Utilization & Discharge Review RN – Health Plan
Baton Rouge, LA
*** This Full Time, Benefits Available, CONTRACT position is expected to last 6 months or longer! ***
Utilization & Discharge Review Nurse Job Summary:
Utilization & Discharge Review Nurse Background:
- Responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
- Performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- 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.
- The Nurse will assist in Discharge Planning activities, to include Care Coordination and/or Case Management, as needed.
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- Prefer Bachelor of Science in Nursing (B.S.N.) or related field.
- CCM or CPUR or similar certification is preferred
- 2 years acute care clinical nursing experience is required.
- 1 year of recent experience in Discharge Planning or 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.
- 1 or more years of experience using 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.