Job Description

• Must have 5+ years of clinical/hospital experience as a RN
• Must have a Compact Nursing License. 
• Must bring 2+ years of Utilization Review/Management experience. 

• Conduct clinical reviews of all prior approval, post-service reviews, customer service and claim requests.
• Determine adequacy of clinical elements of clinical information submitted. Determine essential elements of clinical information for decision-making and request same as appropriate. Make determinations based on medical policy, evidence-based guidelines, and medical necessity.
• Communicate directly with requesting providers to obtain additional clinical information as needed in order to make utilization management decisions.
• Review late and out of network prior approval / referral authorizations for appropriateness and make determination on benefit level based on medical necessity.
• Provide timely and accurate review for procedure/service appropriateness, reconsideration, and appeals based on Rule 9-03, DRF, and NCQA Standards.
• Perform monthly audits related to prior approval processes as well as weekly guidelines to confirm medical necessity and appropriateness of reviewed services.
• Use sound clinical judgment along with appropriate review criteria and practice guidelines to confirm medical necessity and appropriateness of reviewed services.
• Provide support to Provider Relations and Provider Reimbursement in regard to clinical issues relating to new procedure, coding, pricing and provider communications.
• Provide appropriate and timely referrals to the medical director. Identify and report any potential quality of care of services issue to the medical director.
• Perform timely case review information, case entry and updates to case file in the appropriate systems.
• Participate in medical policy committee including research and development of policies and collaboration with participating provider.
• Assist in review of health service delivery and utilization and cost data.
• Assist the claims payer in accurate adjudication of care management approved services as needed.