PHIL- UM USRN- Associate III BPM
Core
Reviewing medical necessity, length of stay, and service intensity for inpatient, outpatient, and ancillary services to ensure appropriate care levels and coordinate patient transfers and discharge planning.
Role type
Utilization Management Nurse
Builds
Care management decisions and provider education for health plans
Domain
Health Insurance / Utilization Management
Required skills
Clinical nursing judgment, regulatory compliance, care coordination, benefits research, provider communication, discharge planning, medical necessity assessment
Preferred skills
MCG Certification, Healthedge HRCM or Guiding Care experience
Technologies
Healthedge HRCM, Guiding Care
Responsibilities
Perform prospective, concurrent, and retrospective reviews of services; Contact medical personnel to recommend alternative treatments; Follow out-of-area/out-of-network services and recommend patient transfers; Establish care plans and coordinate care through the health care continuum; Research and resolve issues related to benefits and member eligibility; Develop and deliver targeted education for the provider community.
Seniority
Mid-level, hands-on IC