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Utilization & Discharge Review RN

Baton Rouge, LA · Healthcare
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: 
  • 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.
Utilization & Discharge Review Nurse Background: 
  • 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.
443.552.7423 (CALL – TEXT – FAX)
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