Utilization Review Nurse - RN
MJ Morgan Group
- Lutherville Timonium, MD
The Utilization Review Nurse will support the clinical review operations needed to assist its membership. This role evaluates the efficiency, appropriateness, necessity of the use of medical services, procedures, and facilities.
Duties and Responsibilities of the Utilization Review Nurse:
- Coordinate with the appropriate managers on a daily basis to assess the inpatient census for appropriate alternative health care service needs.
- Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning (e.g. Milliman Care Guidelines, Interqual).
- Performs on-site and/or telephonic concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines.
- Predicts and plans for patient's needs from pre-admission, through acute and sub-acute care and post-discharge, in collaboration with the member and providers.
- Coordinates with appropriate discharge planning with interdisciplinary health care team to coordinate timely discharge.
- Participates in rounds with the Medical Director.
- Participates in a regular rotation of after hours on call.
- Monitors and facilitates appropriate utilization of resources using clinical criteria.
Education, Experience and Qualifications of the Utilization Review Nurse:
- Degree in Nursing
- Must be a Registered Nurse
- Current unrestricted Maryland Registered Nurse license
- 3-5 years of utilization management experience nursing experience
- 3-5 years of clinical hospital/acute care Proficiency in medical management software utilized for utilization review, medical appeals, and case management.
- Medicaid and Medicare experience a must.
Wednesday, November 7, 2018