Job Search

Utilization Management Registered Nurse (RN) #110275

Job Description

The Utilization Management Nurse (per diem) will perform telephonic medical necessity reviews utilizing established and evidenced based criteria on all designated pre-certification requests, as well as targeted outpatient procedures, services and inpatient admissions.

Essential Functions:
- Review of outpatient and inpatient admissions and/or services; concurrent review and discharge planning for all member's admitted to acute, sub-acute and/or skilled nursing facilities; retrospective review for services not pre-certified and/or reconsiderations. In collaboration with physician and healthcare team, facilitate appropriate resource utilization within contracted and non-contracted facilities.
- Evaluate eligibility and benefit information and educates member and/or family, physician and interdisciplinary healthcare team as to meet the health needs of the member and minimize out of pocket costs.
- Identify and refer appropriate members to case management, disease management, risk management and quality improvement.
- Establish relationships and communicate with members, family, inpatient and outpatient providers and case managers, community resources, skilled nursing staff, member's service, claims, contracts, benefits, appeals, risk and quality management.