This position is responsible for analyzing clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Is responsible for clinical review of all requested services for appropriateness based on clinical criteria. Performs selected member calls to address post hospital discharge services, ongoing durable medical equipment usage and other telephonic follow up identified by UM/CM Management.
This position will facilitate with negotiations for out of network care.
Graduate of an accredited Registered Nursing Program, Bachelor Degree preferred
Basic Knowledge of computer systems
Good typing skills
Excellent customer service skills
Excellent negotiation skills
Minimum of three years diverse clinical experience as RN
Minimum of two years case management and/or utilization review experience