Pediatric Utilization Review RN - Managed Care
Santa Barbara, CA
Utilization Review RN Job Summary:
The Pediatric Utilization Review Nurse is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review.
The UR Nurse will performs reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
They will conduct prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests.
The focus of this position is Pediatric members, including newborns, infants, children, and adolescents. As needed, duties may also include expecting mothers (prenatal, perinatal, and postnatal)
Utilization Review RN Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
CCM or CPUR/CPUM/CPHM or similar certification is preferred
Roughly 1-2 years acute care clinical nursing experience is required.
Around 1-2 years of recent experience in Pediatric Utilization Review or Care Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
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.