UTILIZATION REVIEW NURSE (Care Choices)

POSITION PURPOSE

Conducts pre-certification, concurrent and retrospective reviews of services including Ambulatory Surgeries, DME, Home Health, Acute Inpatient, Sub-acute, Skilled Nursing Facilities, Hospice and Rehabilitation. Applications of prior authorizations and utilization management criteria to ensure that the level of care and services requested are medically necessary, covered benefits and meet the quality of care standards. The incumbent is also responsible for coordinating discharge-planning needs. The goal of the Utilization Review Nurse is to collaborate with the health care team to ensure and promote the delivery of quality, effective health care while maximizing favorable utilization patterns and minimizing unfavorable expenditures.

MINIMUM QUALIFICATIONS Valid license, without restrictions, as a Registered Nurse in the State of Michigan required. Three years of acute care nursing experience is required and two years utilization review experience preferred. Ability to control emotions, remain objective and treat others with respect. Demonstrates effective team behavior across HSM and THP, supporting other team members and working to support achievement of team objectives. Understands relevant accreditation and licensing requirements in assignments. Individual must be able to make independent decisions utilizing appropriate clinical judgment while functioning as a vital part of the health care team. Superior written, oral and interpersonal communication skills. Knowledge of ICD-9, CPT and HCPCS Coding systems. Proficiency using desktop computers, preferably Word and Excel computer programs. One to three years Medical Management experience within a managed care setting, performing utilization management function (i.e., prior authorization, concurrent review or discharge planning). REQUIREMENTS
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