Great opportunity for a Utilization Review RN.
?Approves requests for medical services (inpatient,
pre-certification and concurrent, and outpatient) based on
available information, utilizing nationally accepted guidelines for
utilization management (InterQual) as well as standard of care
information and clinical judgment as appropriate.
?Requests clinical information when needed and refers the request
to secondary medical review with the appropriate information, when
approval for the request cannot be given by the nurse.
?Identifies need for referral of the member to case management
and/or disease management services based on established referral
criteria or individual care need identified during interaction with
members or providers.
?Follows established policy and procedures for timely medical
necessity review, escalation, Peer Review and appeals meeting all
state, URAC and applicable regulatory guidelines.
?Serves as a facilitator to providers for resolution of provider
concerns, complaints and grievances.
?Maintains and ensures the confidentiality of all information
collected during the review process.
?Participates in medical necessity, URAC, clinical and quality
training programs as requested.
?Communicates with providers and members as needed.
?Maintain a positive professional and respectful attitude with
peers and clients.
?Determine and monitor appropriate discharge plans for all approved
We are an equal employment opportunity employer and will consider
all qualified candidates without regard to disability or protected