Utilization Review Nurse - LPN / RN
Peoplelink is a national staffing company that provides effective short and long term staffing solutions to our Customers in the Managed Care Industry. We offer both contract, contract-to-hire and Direct Placement opportunities. Our contract personnel enjoy a full range of Insurance options as well as immediate access to our 401K.
The Utilization Review Nurse serves as the clinical liaison with hospital clinical and administrative staff as well as providing expertise for clinical authorizations for inpatient care. The position requires knowledge of utilization management and/or insurance review processes as well as current standards of care, a strong knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff. The position also requires the ability to work independently in accomplishing assignments, program goals and objectives.
Key responsibilities of the Utilization Review Nurse will include:
• Performing case reviews received via fax, telephonic
• Ensuring that our members receive the proper levels of care
• Coordinating care for members
• Planning member discharges with providers
• Referring patients to disease or case management programs
Utilization Review Nurse Job requirements include:
• Conduct Utilization Reviews (concurrent and retrospective reviews) using Milliman Care Guidelines
• Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and discharge planning activities.
• Confer with physician advisors on regular basis regarding inpatient cases and participate in utilization departmental rounds.
• Track ongoing status of all certification activity and maintain continuing certification (or denial).
• Make initial assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers.
• Work closely with management team in the ongoing development and implementation of health services programs.
• Adhere to quality standards and state UR guidelines, as well as confidentiality of all information, policies, and procedures.
• Advise supervisor of any potential problems as they become evident.
• Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research. Continuous professional development about issues and trends in utilization review.
• Negotiate price, level of care, intensity, and duration of services as appropriate.
• Adhere to company policies, procedures, and reporting requirements.
Please, submit your resume for consideration