Utilization Review Nurse

Job description

The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

Responsibilities

• Determine medical appropriateness of services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination. Perform utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines. Determine medical necessity of each request by utilizing approved evidenced based guidelines / criteria Utilize decision-making and critical-thinking skills in the review and determination of coverage Reviews, documents, and communicates all utilization review activities and outcomes Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines Payor experience required

Requirements

About Hub Technology Group

Relationships. Respect. Understanding. These are just a few reasons why clients and candidates choose to partner with Hub Technology Group, a full service technology staffing company providing solutions catered to the needs of clients and employees. Our services include contract placement, contract to permanent, and permanent placement solutions. We work across all industries and find talent fort technology, human resources, Office Administration, Finance and more.