The Utilization Management Nurse Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.
The Utilization Management Nurse Reviewer works with healthcare providers to ensure appropriate approval of plan benefits. This is accomplished by reviewing clinical information provided to assess medical necessity and the appropriateness of the treatment setting through the application of appropriate policies and criteria (i.e. Milliman). Case assignments may fall in various areas, such as concurrent review of inpatient services, discharge planning, retrospective review, and special needs facilities (SNF).
- Current Active and Unrestricted Nursing License required ( Associate Degree, Nursing Diploma or Bachelor’s degree in Nursing)
- 3 years combined clinical and utilization management experience in a managed health care plan preferred
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