Nurse RN 3

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. #J-18808-Ljbffr