Job Description: This position is responsible for conducting utilization review for medical services utilizing evidence based guidelines, review procedures and policies, clinical decision making, and collaborating with physician reviewers for quality outcomes.
Proficient customer service skills in communicating in writing and verbally with all members of the healthcare team, as well as members.
Proficient in navigating and documenting in real time, as requirement to complete 22-25 outcomes per day (depending on case type assigned).
The Gig: Performs prospective, concurrent or retrospective utilization review/medical management for all services including appropriateness of quality of care based on contract, state, or URAC requirements.
Screens individual situations according to specific criteria to determine if care is appropriate.
Refers cases that fail to meet screening criteria to peer reviewer.
Coordinates and participates in peer-to-peer review as warranted.
With prior management approval, may deviate from criteria with proper justification to authorize the service.
Serves as liaison between peer reviewer, provider, facility and/or subscriber.
Coordinates and participates in appeal process as directed by management.
Trains or serves as a mentor to team members and physician reviewers to ensure reviews and appeals are conducted thoroughly and within specified time frames.
Performs preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care.
Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
Assists in compliance reporting.
What you need to make the cut: Requires active, unrestricted RN license.
3 of recent experience working as an RN in a clinical environment.
Experience in case review preferred.
- provided by Dice