Utilization Review Nurse

Day to Day Responsibilities:

Conducts utilization management activities in accordance with Utilization Management policies and procedures. Responds to calls, conducts certification reviews, facilitates the discharge planning and referral process and coordinates denials with physician advisors for all assigned programs.

• Receives prospective & concurrent requests for service. Coordinates certification reviews for pre-admission, continued stay and retroactive reviews. Interprets and applies clinical information to make delivery decisions and determine appropriate level of care for utilization review activities. (50%)

• Follows departmental policies & procedures for review, determination & notification. Ensures day to day UM processes are conducted in accordance with NCQA, URAC and other regulatory standards. (15%)

• Maintains effective interactions/communication w/ outside providers to assure appropriate delivery of service to members. (10%)

• Reviews requests for medical necessity (referring cases to medical director that require additional expertise). Coordinate denials with physician advisors (10%)

• Documents all activities per APS policies and procedures. (15%)

• Work Environment / Physical Demands:

• Work is performed in a professional office setting, business casual dress environment.

• Working extended hours may be required as needed.

IF IS JOB OPPORTUNITY IS FOR YOU, GIVE ME A CALL AT 321-574-6926 ASAP!

• RN License in NY with 2 years of experience

• Computer literate. This includes simultaneous use of multiple programs and applications; navigating varied file formats; performing copy/paste, save, and update information in multiple formats.

• Utilization Review Experience, the nurse can come from a Hospital, Home Health, or Managed Care company/ health plan

Hello!

My name is Krishna Gapuz and I am a R ecruiting Consultant with Healthcare Support . I specialize in the placement of medical professionals nationwide (both clinical and non-clinical). We just had an amazing opportunity become available for a Utilization Review RN right in Syracuse, NY (Zip Code 13202 ). They are looking to start a qualified candidate as quickly as possible (pending hire requirements). This is an amazing opportunity for a Monday – Friday 8:00a.m.-6:00p.m . job with a stable, prestigious company (This Company is one of the leading providers of Healthcare in your area!)

If you would like to be considered for this opportunity please respond to this Email as soon (today) as possible! (or you’re more than welcome to call me at my office 321-574-6926.

If you opt to respond to this Email, please include:

• • Why did you leave your last position and how long ago (or why are you looking to leave your current position)?
• • How much were you last making (hourly)?
• • If offered, how soon could you start?