Utilization Review
About The Position
This role involves performing precertification and medical necessity reviews for designated referrals and targeted outpatient procedures, services, and inpatient admissions. The position requires telephonic reviews to assess medical necessity using established criteria and guidelines, as well as conducting retrospective emergency department reviews. Additional responsibilities include performing eligibility and benefit reviews, identifying patients for case management, conducting quality improvement reviews, and maintaining communication with various healthcare professionals and departments.
Requirements
- Registered Nurse (RN) with a valid license in GA or Compact.
- 1+ years of experience in Utilization Management (UM).
- 1+ years of experience in managed care.
Nice To Haves
- Experience with MCG or Interqual is preferred.
- Utilization review experience is a plus.
Responsibilities
- Carry out precertification and medical necessity reviews for designated referrals.
- Perform telephonic reviews for medical necessity of targeted outpatient procedures, services, and inpatient admissions.
- Conduct retrospective emergency department reviews.
- Perform eligibility and benefit reviews as necessary.
- Identify patients for case management.
- Conduct quality improvement reviews.
- Communicate with inpatient care coordinators, case managers, SNF/Rehab care coordinators, members, providers, Customer Service, Claims, Contracts and Benefits - Appeals, and Risk Management.
Benefits
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
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What This Job Offers
Career Level
Mid Level
Industry
Administrative and Support Services
Education Level
No Education Listed
Number of Employees
1,001-5,000 employees
