Utilization Review RN

This role is specific to the LTSS department. RN will be responsible for providing case management services and evaluating the necessity/appropriateness/efficiency of the use of Medical Services for Long-Term Support Services (LTSS).

Will be responsible for collaborating with providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. May also manage appeals for services denied. Provides plan of care for members based on authorization and concurrent review. Provides monthly telephonic outreach to ensure members needs are assessed and met based on information.

Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

MAJOR JOB DUTIES AND RESPONSIBILITIES

• 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.

• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.

• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

• Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.

• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.

• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. 

Additional Info:

*possible remote opportunity after training if candidate demonstrates understanding of processes and policy expectations*