Morgan Stephens represents the nation’s top healthcare systems offering the highest compensation and benefits to our top candidates. We are created and managed by experienced industry professionals in healthcare. As a leading provider of contract, contract to perm, and direct placement recruiting services to healthcare organizations throughout the United States, we have successfully served the needs of our employees and clients by placing thousands of quality healthcare professionals into organizations seeking top talent.
The Utilization Review Nurse uses clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. The Nurse assists in determining appropriateness, quality and medical necessity of referral requests using pre-established guidelines. This position is responsible for providing services for patients of Coordinated Health Care employer groups with catastrophic illness and/or injuries. They also function as a clinical resource for other staff in the company such as utilization review, patient services, disease management, and sales. This position may be assigned cases in pre-authorization areas, in skilled nursing facility review or in concurrent review.
Active and Unrestricted LPN or RN licensure.
LPN/RN experience; Utilization Management (UM) experience.
General knowledge of UM and Managed Care preferred.
Use of InterQual guidelines preferred.
Experience at meeting deadlines by prioritizing work flow preferred.
Physician group experience preferred.
Strong knowledge nursing requirements in a clinical setting.
Knowledge of utilization management programs as related to pre-set protocols and criteria.
Knowledge of health plans.
Medical specialty procedures and diagnoses.
Knowledge of Ohio health plans and differences between commercial and advantage plans preferred.
Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.
Ability to read and interpret benefit contract specifications.
Ability to understand and follow established criteria and protocols used in managed care functions.
Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
Ability to apply clinical judgment to complex medical situations and make quick decisions.
Strong organization skills.
Effective telephone and computer data entry skills required.
Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.
Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.
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