RN-Utilization Review - Full-time / Part-time

PRIMARY RESPONSIBILITIES

• Coordinates and/or manages medical management review cases identified for utilization management, including review and interpretation of medical records and clinical updates, according to standards used to determine medical necessity, appropriateness of care, and coordination of care. Utilize decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Ensure accurate and timely submission of all administrative and review-related documents to appropriate parties.
• Follow established utilization management policies for referrals to medical directors. Identify and refer potential cases to Case and Disease Management.
• Interact with other departments, providers, and facilities to enhance medical management programs, through coordination and continuity of care. Promote communication and collaboration.
• Provides coverage for medical management reviews and telephones, as required.
• Collaborate with other departments/staff to assist in developing, monitoring, revising, and/or improving medical management programs.
• Assists with updates to the clinical documentation system through recommendations for improvement or integration with other documentation systems, as appropriate.
• Maintain production goals and QA standards.
• May provide education and training resources to staff involved in utilization management.
• Promotes timely and effective communication based on individual and/or situational requirements and utilizes appropriate means to ensure adequate information flow.
• Supports compliance with NCQA and governmental requirements, as appropriate to the position.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing

EXPERIENCE

• Three years’ clinical nursing experience