RN - Case Manager

Utilization Review Nurse

The Utilization Review Nurse is responsible for the day-to-day management of health plan members in acute care and/or rehabilitative facilities. The Utilization Nurse actively monitors the appropriateness of care received by plan members in various settings, including acute hospitals and rehabilitation facilities. The Utilization Nurse applies member benefits and medical criteria to determine authorization of services in coordination with Medical Directors. The Utilization Nurse proactively initiates discharge planning for members, including the identification of post-discharge needs and coordination of post-discharge referrals/services. The Utilization Nurse communicates verbally and in writing authorization and/or denial of covered services with providers, facilities, and members. The Utilization Nurse is part of administrative and clinical teams in the area of assignment. Clinical knowledge is maintained and updated, and the Utilization Nurse must uphold acceptable documentation and quality standards. Excellent verbal and written communication skills are required to effectively interact with enrollees, physicians, facility staff, and management staff. The role requires excellent interpersonal skills and a positive attitude to project a favorable image of the Managed Care Program. Computer skills are necessary for working with a variety of applications and online systems. The ability to negotiate and resolve conflicts with external customers is essential.