Utilization Review Nurse

Job Description

Use established medical policy and guidelines to perform prospective, concurrent, and retrospective medical necessity review of post-acute care services to ensure medical necessity for appropriate setting, appropriate length of stay, including appeal requests initiated by providers, facilities and members.

Will coordinate care through the health care continuum including member outreach.

Provides support and alternative care support for members not appropriate for post-acute care service as well formulate discharge readiness for members transitioning from a post-acute care setting to a lower level of care.

Should have experience with InterQual

Requirement :

Bachelor’s degree in nursing, allied health, business, or related field preferred.

Two to four years of clinical experience which may include post-acute care, home care, acute patient care, discharge planning, case management, and utilization review, and caring for aging population in the home or post-acute care setting, etc.

Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.

One year health insurance plan experience or managed care environment preferred.

Registered Nurse with current unrestricted Michigan Registered Nurse license required.