Utilization Review Nurse/rn
Concurrent review and authorization of inpatient/hospital services using nationally recognized guidelines(MCG- Milliman Care Guidelines), assigning lengths of stay, determining medical necessity and individual patient health needs and availability of services and resources based in accordance to benefit provisions of subscriber's health plan. Discharge planning, case management, care management, conducting disease management programs and appropriate referrals to disease management programs.
- Registration, review and authorization of inpatient hospital and skilled nursing stays using daily review information consisting of treatments and delivery of care based on medical necessity.
- Assigning length of stay based on diagnosis/ICD-9, ICD-10, procedures and review necessity for ongoing hospital and skilled nursing stays, Inpatient pre-certification, concurrent and retrospective review of delivery of care and treatment in hospital setting.
- Identify, evaluate, and initiate case management on patients based on diagnosis/ referrals to Case management/Disease Management Programs.
- Perform telephonic case management on discharged patients to assess needs in the home, follow up with physicians and trouble shoot in order to deliver appropriate and timely care and prevent readmissions.
- Execute contracts/Letters of Agreements with providers to facilitate care and contain costs, reviewing appeals/grievances.
- Experienced in working in a managed care environment.