Description

You will perform frequent case reviews, check medical records, and speak with care providers to assess the appropriateness of care, applying clinical guidelines to support member health outcomes.

Requirements

• Active, unrestricted RN licensure (US or compact multistate)
• Associate or Bachelor's degree in Nursing or graduate of accredited nursing school
• MCG or InterQual tooling experience
• 1+ year utilization review experience in managed care
• 1+ years clinical experience including at least 1 year in acute care setting (ER or hospital)

Responsibilities

• Complete medical necessity and level of care reviews using clinical judgment and guidelines
• Obtain and assess clinical information via telephone and fax
• Meet required decision-making SLAs
• Refer members for further care engagement when needed
• Ensure compliance with applicable laws and regulations