Utilization Review Nurse- RN

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Provide professional assessment and review for the medical necessity of treatment requests and plans. Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed. Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall outside of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services, complete non-certification letters when appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs. Complete documentation for all reviews in appropriate documentation software. Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete all required yearly training per company’s expected time limit. Complete and pass all annual testing including IRRA at 90% or higher. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete all required yearly training per company’s expected period