Utilization Management Nurse (USRN)

UST

Taguig, National Capital Region, Philippines

6d ago

Job Description

Role : Inpatient Concurrent Review US RN / Utilization Management Nurse

Primary responsibilities :

Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures

Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits

Conducts initial benefit determination reviews

Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review

Consults with UM Medical Director to review requests that do not meet medical necessity

Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

Generates appropriate written correspondence to providers and / or members in accordance with UM policies and procedures

Adheres to company policies and procedures regarding confidentiality and privacy

Qualifications :

Registered Nurse with a current, valid unrestricted US license

Minimum of 1-year experience in Utilization Management

Experience utilizing UM criteria including MCG or InterQual

Minimum of three (3) years clinical nursing experience in an ambulatory or hospital setting

Proficient computer skills and experience with Microsoft web-based applications

Experience in managed care and health insurance required

Ability to communicate effectively verbally and in writing in English

Ability to work holiday and weekend rotation

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