RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.
Registered Nurse (RN) with a valid, current, unrestricted license in the state of operations. 3 years of clinical experience in a Physician's office, Hospital/Surgical setting, or Health Care Insurance Company. Knowledge of medical terminology and procedures. Verbal and written communication skills. Utilization Management experience. JOB QUALIFICATIONS (Preferred): MCG or InterQual experience
This position is responsible for performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness, and quality of medical/surgical services, and serving as liaison between providers and medical and network management divisions. Collects clinical and non-clinical data. Verifies eligibility. Determines benefit levels in accordance to contract guidelines. Provides information regarding utilization management requirements and operational procedures to members, providers, and facilities.
Best Value
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Advanced
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Basic
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