Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health.
Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services.
Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization.
Maintain accurate and organized documentation of all utilization management activities.
Participate in quality improvement initiatives and assist in developing clinical guidelines.
Monitor and report on utilization trends to management, identifying areas for improvement.
The Profile
Qualifications
Bachelor's Degree in Nursing (BSc Nursing) or equivalent.
Minimum of 2 years of clinical experience in a hospital or healthcare setting.
Active and unrestricted Registered Nurse (RN) license in the United States.
Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual).
Proficient in medical terminology, anatomy, and physiology.
Strong analytical and problem-solving skills.
Excellent communication skills, both written and verbal.
Proficient in Microsoft Office applications.
Preferred Qualifications
Experience with Medicaid, Medicare, and Managed Care programs.
Previous experience in utilization review or case management.
Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus.
The Employer
Our client specializes in Healthplan IT solutions, offering a comprehensive suite of services designed to enhance efficiency and improve digital presence for health plans and Third-Party Administrators (TPAs).
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