Utilization Management RN 
Remote -- California
 
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.
• 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.

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#CLINICAL
 

Mikala Bennett
Search Consultant
CareNational
mikala@carenational.com
480.568.7149 (CALL – TEXT – FAX)
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