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RN- Registered Nurse- Utilization Review-Utilization Management-Managed Care

RN- Registered Nurse- Utilization Review-Utilization Management-Managed Care

Job Description

JOB SUMMARY: Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities.  Licensed  RN responsible for clinical review of all acute and subacute services for appropriateness based on medical criteria.  This individual is responsible for the management of healthcare resources necessary and appropriate for achievement of desired acute and subacute outcomes and the coordination of alternative levels of care for membership.


 PRIMARY RESPONSIBILITIES:


 


1.      Performs on-site and/or telephonic review of acute and subacute services.


2.      Predicts and plans for patient’s needs from pre-admission, through acute and subacute care and post-discharge, in collaboration with the member.


3.      Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.


4.      Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.


5.      Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.


6.      Strives to maintain quality care while effectively utilizing resources.


7.      Identifies and reports any quality or utilization issues to the Medical Director.


8.      Acts in conjunction with the clinical team related to discharge planning e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy, durable equipment and disposable supplies.


9.      Documents all activities in the appropriate system(s) on a timely basis.  


10.  Participates in rounds with the Medical Director.  


11.  Review Plan appeal items for concurrent and retrospective reviews as required and requested. 


12.  Monitors and facilities appropriate utilization of resources utilizing clinical criteria.


13.  Tracks and reports trends of inappropriate utilization of resources to the Medical Director.


14.  Participates in a multi-disciplinary clinical team to achieve positive member outcomes. 


15.  Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.


16.  Utilizes effective communication, conflict management and negotiation skills. 

Job Requirements

Education and Experience:


·        Currently licensed RN with three years experience in health care, case management, discharge planning, utilization management, or behavioral health. 


·        Two years of Utilization Management or Hospital/Acute care experience required.


·        Experience working on the community level and with community agencies preferred.


 


Certification and Licensure:


·        Current State RN license


·        Certified Professional Utilization Review  (as required by Plan)



Abe Ghebrehiwet
Senior National Account Executive
Nurse Resolutions
888.411.2228 ext 204. Toll Free
407.341.9647. Cell
407.982.7508. Fax
www.nurseresolutions.com
[Click Here to Email Your Resumé]

utlization review, utilization management, case manager, case management, insurance albuquerque, new mexico

Job Snapshot

Employment Type Full-Time
Job Type Nurse, Health Care, Insurance
Education Not Specified
Experience At least 5 year(s)
Manages Others Yes
Industry Healthcare - Health Services, Insurance, Managed Care
Required Travel Not Specified
Job ID abe
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RN- Registered Nurse- Utilization Review-Utilization Management-Managed Care


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