Utilization Review RN

These candidates will be working in the continued stay review department. They will be looking at emerging urgent inpatient admissions for medical necessity. Strong computer skills, positive attitude, and ability to hit high production goals is what the manager is looking for here. Expected to review 20 cases a day with a 95% accuracy rate.

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 precertification, inpatient, retrospective, out of network andappropriateness of treatment setting reviews to ensure compliancewith applicable criteria, medical policy, and member eligibility, benefits,and contracts.

• Ensures member access to medical necessary, qualityhealthcare 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.