Utilization Review Nurse
Med-Metrix
This position requires local presence. Please view similar jobs below.
Experience these exceptional benefits when you join Med-Metrix!
- 8-Hour Shifts
- Day 1 HMO with 2 of your dependents covered for FREE
- Group Life Insurance
- Medical Cash Allowance
- Rice Allowance
- Clothing Allowance
- Holiday Gift
- Bereavement Assistance
- Free Lunch Daily
- Paid Time Off
- Training and Staff Development
- Employee Engagement Activities
- Opportunities for Internal Mobility
- Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures.
- Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits.
- Conducts initial benefit determination reviews.
- Consults with UM Medical Director to review requests that do not meet medical necessity.
- Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Generates appropriate written correspondence to providers and/or members in accordance with UM policies and procedures.
- Adheres to company policies and procedures regarding confidentiality and privacy.
- Must have valid PHRN License; USRN license is a plus.
- Minimum of 1 - 2years experience in Utilization Management.
- Experience utilizing UM criteria including MCG or InterQual.
- Minimum of three (2) years clinical nursing experience in an ambulatory or hospital setting.
- Proficient computer skills and experience with Microsoft web-based applications.
- Experience in managed care and health insurance required.
- Ability to communicate effectively English, both written and verbal.
- Ability to work holiday and weekend rotation.
- Work Set-Up: Hybrid
- Work Schedule: Night shift, US hours; PH holidays and weekend rotation.
- Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
- Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
- Work Environment: The noise level in the work environment is usually minimal.
Vacancy posted a month ago
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