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.
Other duties as assigned.
Skills:
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4.
Experience in utilization management and/or medical review preferred.
Specialized Knowledge & Skills:
Ability to prioritize and make sound nursing judgments through critical thinking
Excellent verbal and written communication skills
Ability to build collaborative relationships
Attention to details
Ability to interpret complex documentation
Education:
Registered Nurse License, active and unencumbered state license in the state where job duties are performed is required.
BSN preferred.
Four (4) years of clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.