Description

We are seeking a UM Review Nurse to ensure the quality and cost-efficiency of medical care by applying clinical knowledge and implementing policies and guidelines for emergency, urgent and continued stay evaluations. The detailed examination of medical necessity and level of care for required services will be part of your daily tasks, where, based on case findings, you may need to refer to Medical Directors for reviews.

Duties & Responsibilities: • Facilitate, coordinate and approve medical referrals that meet specific criteria as a Utilization Management Nurse Specialist RN • Ensure timely and exact referral determinations and notifications based on the referral status • Prepare and generate approval, alteration, and refusal communications to notify members and providers of referral determination • Monitor any inpatient setting admissions actively • Conduct telephic and/or on-site review for admission and concurrent review, work in collaboration with onsite staff, physicians, providers, members/family to get a successful discharge plan • Collaborate with the UM Director and Medical Director for case reviews for pre-service, concurrent, post-service, retrospective claims medical review, and occasionally, appeals • Function as a department guide for medical service requests/referral management and procedures • Handle incoming calls from providers, deal with complex calls professionally, and research to find accurate and timely resolution steps • Follow-up with the caller to provide a response or resolution steps • Answer all inquiries professionally and courteously • Support team engagement, programs, and events to encourage a positive and productive workplace • Generate proper member and provider communication for all determinations within the deadlines outlined by the latest department policy.

Requirements

Active LVN license

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