Registered Nurse

Registered Nurse

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Essential functions include providing concurrent review and prior authorizations (as needed) according to policy for members as part of the Utilization Management team. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care. Maintains department productivity and quality measures. Attends regular staff meetings. Assists with mentoring of new team members. Completes assigned work plan objectives and projects on a timely basis. Maintains professional relationships with provider community and internal and external customers. Conducts self in a professional manner at all times. Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. Consults with and refers cases to medical directors regularly, as necessary. Complies with required workplace safety standards.

Knowledge/skills/abilities include demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities. Work independently and handle multiple projects simultaneously. Knowledge of applicable state, and federal regulations. In depth knowledge of Interqual and other references for length of stay and medical necessity determinations. Experience with NCQA. Ability to take initiative and see tasks to completion. Computer literate (Microsoft Office Products). Excellent verbal and written communication skills. Ability to abide by policies. Ability to maintain attendance to support required quality and quantity of work. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

Required education: Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree). Experience with Medicaid and Medicare denial letters. Familiar with MCG and InterQual criteria. Familiar with Medicaid and Medicare time frames. Required experience: Minimum 4+ years of clinical practice. Preferably hospital nursing, utilization management preferred. Required licensure/certification: Active, unrestricted State Nursing (RN) license in good standing.