Utilization Management Nurse (USRN)
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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