Remote Utilization Review Nurse (RN) – Compact License

Nurse Reviewer -Utilization Management / Inpatient

6+ Month Contract – REMOTE

Compact License Required

The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

• Determine medical appropriateness of services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
• Perform utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
• Determine medical necessity of each request by utilizing approved evidenced based guidelines / criteria
• Utilize decision-making and critical-thinking skills in the review and determination of coverage
• Reviews, documents, and communicates all utilization review activities and outcomes
• Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines
• Payor experience required

REQUIRED FOR THIS JOB:

• Compact RN License
• Nursing Dimpoloma or Degree
• 2+ years of Utilization Review experience with Interqual and Inpatient Review experience