Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards. Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care. May establish care plans and coordinate care through the health care continuum including member outreach assessments. Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities. Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed. Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.  This position description identifies the responsibilities and tasks typically associated with the performance of the position.  Other relevant essential functions may be required.

 

Requirements:

Registered Nurse with current, unrestricted US Registered Nurse license  3+ years of direct, clinical nursing experience  2+ years’ experience in US Healthcare in utilization management or case management  MCG Certification will be a plus Healthedge HRCM or Guiding Care experience is a plus