Utilization Review Nurse

Job description

• Responsible for conducting timely reviews of all requests for services required to meet medical necessity criteria to include reviewing pre-certification for outpatient and inpatient services • Applying criteria to inpatient admissions and performing concurrent review functions, identifying discharge planning needs and referral of members to case management. • Evaluates clinical information submitted by providers against plan review criteria and benefit guidelines • Utilizes clinical information to determine if criteria for medical necessity and benefit guidelines are met Utilizes professional judgment to determine if additional information is required, then follows through to obtain additional information prior to making a decision • Documents all pertinent case information and dispositions for approvals and denials • Refers all cases failing to meet interqual medical necessity criteria to Medical Director for review and final determination • Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for members • Acts as a liaison to assure services are provided in the least restrictive, most cost effective and clinically appropriate setting • Works with the Utilization Management Manager, the Medical Director and providers to ensure that complete medical information is available to allow utilization management decisions to be made within The Plan’s standards for decision making • Identifies potential members who may benefit from case management services and facilitates referral to the program • Identifies and resolves any problems that could interfere with provider’s continuity and coordination of care of members and refers unresolved problems to Manager • Creates and maintains monthly reports on inpatient activities • Performs other related duties and projects as assigned • Adheres to ACFC policies and procedures • Supports and carries out our Mission & Values. • Associates RN degree required, Bachelor’s degree preferred • Two years of experience in managed care quality assurance or utilization review • RN must have two years of experience in an acute care hospital. Thanks Warm Regards Ricky Bansal 732-429-1925 Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow. We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity. Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.