Nurse RN 3

Day to Day Responsibilities
The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned to members based on an alpha split and then review clinical information provided by facilities to determine medical necessity when our members admit. You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.
• Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using client and CMS evidenced based guidelines, policies and nationally recognized clinal criteria for client's Medicare line of business.
• Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compl...