• Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
• Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care
• Conduct discharge planning
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Enter and maintain pertinent clinical information in various medical management systems
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in an acute care setting. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current state’s RN license.
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