Utilization Review Nurse

Mô tả công việc

Job Duties: Review authorization requests for medical appropriateness and correct contracted vendor. Liaison with designated Medical Director for complex authorization requests. Maintains knowledge of current contractual arrangement with the Health Plans and vendors. Functions as clinical resource for benefit interpretation.  Researches complicated cases. Screens for CCS diagnosis and refers appropriately. Screens all tertiary referrals through Compliance Director. Oversees UM Coordinators to ensure accurate and timely processing of the authorizations. Assists in preparing annual evaluations for UM Coordinators. Responsible for presenting the clinical criteria to support denial of services. Attends monthly UM Committee meeting for related groups and assists in the preparation of the agenda, minutes, and packet. Identify any patterns of over/under utilization and refer to appropriate source. Refer appropriate cases to the Outreach Department. Perform related duties or fill in for others in the department as requested by the Director of Compliance and UM. 14. Foster positive interaction and relationships with all internal departments as well as       cultivating positive working relationships with external contacts.