Utilization Management Nurse (84124)
Primary Responsibilities
The Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations.
Essential Functions
• Perform concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services.
• Follow and maintain compliance with CMS requirements, may include after-hours, holiday and weekend coverage.
• Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member’s health need.