RN - Case Manager

Utilization Review Nurse

This position involves the day-to-day management of health plan members in acute care and/or rehabilitative facilities. The Utilization Review Nurse actively monitors the appropriateness of care received by plan members in various settings, including acute hospitals and rehabilitation facilities. The nurse applies member benefit and medical criteria to determine the authorization of services in coordination with medical directors. Proactively initiating discharge planning for members is a key responsibility, including the identification of post-discharge needs and coordination of referrals/services. The nurse communicates authorization and/or denial of covered services verbally and in writing with providers, facilities, and members. As a member of administrative and clinical teams, the nurse maintains and updates clinical knowledge and must uphold acceptable documentation and quality standards. Excellent verbal and written communication skills are essential for effective interaction with enrollees, physicians, facility staff, and management. Strong interpersonal skills and a positive attitude are required to represent the Managed Care Program effectively. Computer skills with various applications and online systems are necessary. Knowledge of standards and criteria sets, including InterQual, is essential. The ability to negotiate and resolve conflicts with external customers is also required.