Utilization Review RN

Daily 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 

• 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

• Facilitates member care transition through the healthcare continuum 

• Refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications

Hours for this Position: Monday-Friday (40 hours/week)

Advantages of this Opportunity:

• Competitive salary, negotiable based on experience

• Benefits offered, Medical, Dental, and Vision

• Fun and positive work environment

• Weekly deposit options