Utilization Review Nurse

Day to Day Responsibilities:

Conducts utilization management activities in accordance with Utilization Management policies and procedures. Responds to calls, conducts certification reviews, facilitates the discharge planning and referral process and coordinates denials with physician advisors for all assigned programs.

• Receives prospective & concurrent requests for service. Coordinates certification reviews for pre-admission, continued stay and retroactive reviews. Interprets and applies clinical information to make delivery decisions and determine appropriate level of care for utilization review activities. (50%)

• Follows departmental policies & procedures for review, determination & notification. Ensures day to day UM processes are conducted in accordance with NCQA, URAC and other regulatory standards. (15%)

• Maintains effective interactions/communication w/ outside providers to assure appropriate delivery of service to members. (10%)

• Reviews requests for medical necessity (referring cases to medical director that require additional expertise). Coordinate denials with physician advisors (10%)

• Documents all activities per APS policies and procedures. (15%)

• Work Environment / Physical Demands:

• Work is performed in a professional office setting, business casual dress environment.

• Working extended hours may be required as needed.

IF IS JOB OPPORTUNITY IS FOR YOU, GIVE ME A CALL AT 321-574-6926 ASAP!