Registered Nurse

JOB RESPONSIBILITIES:

–         Processes requests for authorization from in-network providers and communicates in a timely manner when the decision has been made by the Medical Team .

–         Collects, reviews, and evaluates information necessary to reach prospective, concurrent and retrospective decisions using objective evidence-based clinical criteria.

–         Suggests alternate care plans, makes recommendations and coordinates with the Provider/Medical Team for appropriate utilization of services.

–         Documents case reviews, associated communications, and outcomes in the electronic case file.

–         Presents cases to the site Physician and/or Medical Director for review and determination. Works closely with the Physician and/or Medical Director to ensure that medical review of specific cases occurs timely and meets standards for decision turnaround times.

–         Participates in periodic inter-rater reliability testing on medical necessity criteria application.

–         Recognizes and refers potential quality of care concerns to Quality Management.

–         Maintains confidentiality of all information in compliance with State and Federal Law

Schedule: 8:30AM – 5:30PM Monday-Friday

Hybrid: 1/2 in Office & 1/2 WFH (remote)

Weekly Hours: 40

QUALIFICATIONS:

Education: BSN required

Experience:

–         Minimum of three to five (3 – 5+) years’ experience in a hospital or home care clinical setting.

–         Knowledgeable about Medicare and Medicaid guidelines.

–         Case Management and discharge planning experience is beneficial.

–         Two to three (2 – 3) years of Utilization Review experience at a Managed Care Organization is preferred.