Job Description

Utilization Management Nurse

Job Description

Responsible for reviewing and documenting prior authorization and concurrent stay requests, as well as member case histories, in compliance with policies, procedures, clinical criteria (MCG), and member coverage. This role requires remote interfacing with members, providers, facilities, medical directors, intake staff, case managers, and other departments internally.

Responsibilities

  • Review and document prior authorization and concurrent stay requests.
  • Evaluate member case history in compliance with policies and procedures, clinical criteria (MCG), and member coverage.
  • Interface remotely with members, providers, facilities, medical directors, intake staff, case managers, and other internal departments.
  • Determine the medical necessity of post-acute stays using clinical judgment and MCG criteria.
  • Route cases to the medical director for denial if the...

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