Nurse RN 3

Job Title

Day to Day Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies, and nationally recognized clinical criteria for the Medicare line of business.
• Ensure discharge planning at appropriate levels of care for the members' needs and acuity.
• Durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
• Prepare and present cases to Medical Director for oversight/necessity determination and communicate determinations to providers and members to comply with state, federal, and accreditation requirements.
• Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identify potential quality of care issues, service, or treatment delays, and intervene as clinically appropriate.
• Refer to Case Management when there are acute inpatient needs affecting discharge.
• Attend staff meetings, clinical rounds, and weekly huddles.
• Maintain quality and productivity metrics for all casework.
• Maintaining HIPAA compliant workspace for telework environment.

Disqualifiers/ Dislikes on Resumes:

• No Clinical experience.
• Many Short-term Jobs without explanation.
• Poor Computer Skills.

Education Requirements

• Associate's degree in nursing required.
• Bachelor's degree preferred.

Software Skills Required

• Windows
• Excel
• Outlook

Required Skills (top 3 non-negotiables)

• Strong communication and critical thinking.
• Minimum of 2 years of Utilization Management experience.
• Strong clinical background with a minimum of 5 years' experience doing direct patient care in the hospital inpatient setting.

Preferred Skills (nice to have)

• ER and/or ICU experience.
• MCG experience.
• Experience managing Medicare cases.