UM RN
Core
Review, research, and authorize requests for authorization of elective, direct, ancillary, urgent, and emergency services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care.
Role type
Utilization Review Registered Nurse
Builds
Health insurance operational infrastructure
Domain
Health insurance / Managed care
Required skills
Registered Nurse license, clinical knowledge of patient care and health care delivery processes, knowledge of policies and procedures, member benefits, and community resources, knowledge of applicable accreditation standards and regulations, ability to apply clinical criteria/guidelines for medical necessity
Preferred skills
Case Management certification, 1 year health insurance plan or managed care environment experience
Technologies
Microsoft Office Suite
Responsibilities
Review, research, and authorize requests for authorization of elective, direct, ancillary, urgent, emergency services; Analyze, research, respond to, and prepare documentation related to retrospective review requests and appeals; Establish, coordinate, and communicate discharge planning needs; Analyze patterns of care associated with disease progression; Research and resolve issues related to benefits, member eligibility, and coordination of benefits; Follow out-of-area/out-of-network services and make recommendations on patient transfer
Seniority
Mid-level, hands-on IC