Utilization Review RN

• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources.

• Applies clinical knowledge to work with facilities and providers for care coordination.

• Works with medical directors in interpreting appropriateness of care and accurate claims payment.

• May also manage appeals for services denied.

• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.