Utilization Management RN


Ensures that services are delivered and documented in a manner that balances quality of care with efficiency, cost-containment and compliance.

Roles Responsibility
Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases. Assists departmental staff with issues related to Milliman (or similar) guidelines, status determination, medical records/documentation, precertification, reimbursement and concurrent denials appeals. Collaborates closely with case managers to make sure status’ and level of care is accurate. Communicates with payers as needed to ensure patient accounts are secured. Assesses and coordinates patient's discharge planning needs with members of the *****care team. Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.
Desired Qualification
BSN Bachelor of Science in Nursing
Full Time
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