Utilization Management Review RN (United States)

Duties:

• Utilization Management: Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
• Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Workflow: Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.
• Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.