Job Description

• Perform prospective, concurrent and retrospective review of inpatient services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.
• Responsible for the review of precertification, admissions approvals, telephone triage, and/or benefit interpretation.
• May be required to enter or reference data via PC.
• Other related skills may be required to perform this job.
• The maximum hourly rate reflects budget estimates only and does not reflect the final negotiated rate.

• Bachelor’s degree in nursing, allied health, business, or related field preferred.
• Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review with another insurance provider, etc.
• Demonstrates clinical knowledge and experience relative to patient care and health care delivery processes.
• One (1) year health insurance plan experience or managed care environment highly preferred.
• Registered Nurse with current unrestricted Michigan Registered Nurse license required.

Top 3 Required Skills/Experience –

• 2 years acute care experience with an unrestricted Registered Nurse license
• ICU/ER preferred
• should not just be 2 years in a specialized field such as NICU/OB/BH/Substance Abuse
• InterQual/MCG or other utilization review experience preferred

Required Skills/Experience – The rest of the required skills/experience. Include:

• Advanced computer skills
• 40+ WPM typing
• Good verbal and written communication skills
• Organizational skills

Preferred Skills/Experience – Optional but preferred skills/experience. Include:

• Utilization Review experience at a previous insurance company (medical, surgical admissions)
• Utilization Review experience in an acute care setting

Education/Certifications – Include:

• Must be a RN with an unrestricted Registered Nurse license