Nurse Hospital Care - RN

Registered Nurse

Utilizes clinical information to determine if criteria for medical necessity and benefit guidelines are met. Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet interqual medical necessity criteria to Medical Director for review and final determination. Works with the Utilization Management Manager, the Medical Director and providers to ensure that complete medical information is available to allow utilization management decisions to be made within The Plan's standards for decision making. Identifies potential members who may benefit from case management services and facilitates referral to the program. Identifies and resolves any problems that could interfere with provider's continuity and coordination of care of members and refers unresolved problems to Manager. Performs other related duties and projects as assigned. Adheres to ACFC policies and procedures. Education and Training: Associates RN degree required, Bachelor's degree preferred. Experience: Two years of experience in managed care quality assurance or utilization review. preferred RN must have two years of experience in an acute care hospital.