Utilization Review RN

• Evaluate clinical information submitted by providers against plan review criteria and benefit guidelines

• Utilize clinical information to determine if criteria for medical necessity and benefit guidelines are met

• Document pertinent case information for approvals and denials- refer cases failing to meet Interqual to Medical Director

• Act as liaison to ensure services are provided in the least restrictive, most cost effective and clinically appropriate setting

• ID and resolve problems that could interfere with provider’s continuity and coordination of care of members- refer unresolved problems to the manager