Utilization Management RN Wanted!

• Review precertification requests for medical necessity.

• Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.

• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

o promote improved quality of care and/or life

o promote cost effective medical outcomes

o prevent hospitalization when possible and appropriate

o promote decreased lengths of hospital stays when appropriate

o prevent complications in patients under our care when possible

o provide for continuity of care

o assure appropriate levels of care are received by patients

• Provide appropriate referrals to Case Management.

• Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.

• Maintain accurate records of all interventions.

• Gathers all pertinent information from providers and facilities to ensure physician reviewers have sufficient information to make a decision to approve or deny services.

• Coordinates with non-clinical staff to ensure all documentation is completed timely and in a professional manner.

• Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider.