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Utilization Review RN
Washington , DC 20003
Posted 1 week ago
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Utilization Review RN - Managed Care
This is a full-time, benefits available, CONTRACT opportunity, expected to last 2-3 months, or longer! Utilization
Utilization Review Nurse Background:
- The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
- The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
- Current, valid, and unrestricted state Registered Nurse (R.N.)license.
- Bachelor degree and/or a CCM or CPHM /CPUM/CPUR or similar certification is preferred
- At least 3years of acute care clinical nursing experience is required.
- Requires 1-2 years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
- Knowledge of guidelines for Medicaid and related state programs is required.
- Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
- Computer skills to include Microsoft Word, Excel, database use, and basic data entry.