USRN — Utilization Management

SCHEDULE : Night Shift

WORK SETUP: Full Remote — Day I onsite for equipment setLw; occasional onsite work as Backup internet required; laptop provided.

ROLE OVERVIEW

Perform prospective, concurrent, and retrospective reviews of care to ensure medical necessity, appropriate length of stay and level of care, including appeal requests from providers, facilities, and members.

KEY RESPONSIBILITIES

. Review inpatient, ambulatory, and ancillary services for medicd necessity and level of care

• PrepMe documentation for retrospective reviews and appeals per regulatory and NCQA standards

• Recommend treatrnent, service Evels, or length Of Stay using approved dinical protocols

. Review out-okletwork services and recornmend transfers to in- network care

• Establish care and coordinate care through the health care cmtinuum

• Chrdinate discharge With internd and entities

. Research and resolve issues on benefits, eligibity, and coordination Of benefits

• Devdop and deliver provider education on policies, procedures,

REQUIRED SKILLS & QUALIFICATIONS

. Active, unrestricted LJSRN license required 2+ years Of experience; bedside nursing experieme preferred

• 1+ year Of health plan or 0M experience

• Experience in Medicare policy

• Experience in MCG preferred

• HealthEdge HRCM Or Guiding Care experience a plus