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RN-Registered Nurse Care Review Clinician III-Managed Care

RN-Registered Nurse Care Review Clinician III-Managed Care

Job Description

Job Summary

Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing  ealthcare members with the right care at the right place at the right time.  Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.  Mentors and trains new team members.  Assesses services for  Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Essential Functions

• Provides concurrent review and prior authorizations (as needed) according to  policy for members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Assist with leadership responsibility in collaboration with the Supervisor of Utilization Management as required.
• Provides training and mentoring to Utilization Management staff as appropriate.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for  embers including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Provides assessment, training and mentoring of team members in a lead capacity.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.

Job Requirements

Required Education: 
Bachelor’s Degree and completion of an accredited Registered Nursing (RN) program. (a combination of experience and education will be considered in lieu of degree).

Required Experience:  
Minimum five years of clinical practice and three years Managed care experience with utilization management and/or case management.
Required Licensure/Certification:
Active, unrestricted State Registered Nursing license in good standing.

Preferred Education:
Masters degree in nursing or health related field.

Preferred Experience:

Abe Ghebrehiwet

Senior Account Executive

Nurse Resolutions

888.411.2228. X 204 Toll Free

407.982.7508. Fax

[Click Here to Email Your Resumé]

case manager, case management, utilization review, utilization management

Job Snapshot

Employment Type Full-Time
Job Type Nurse, Health Care, Insurance
Education Not Specified
Experience Not Specified
Manages Others No
Industry Managed Care, Healthcare - Health Services, Insurance
Required Travel Not Specified
Job ID abe
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RN-Registered Nurse Care Review Clinician III-Managed Care

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