Utilization Management Review RN Job in Lakewood, Ohio US
Utilization Management Review RN
This position is responsible for providing clinical expertise for the referral service specialists and be an active resource in decision making regarding prospective and concurrent review, discharge planning, and continuity of care. Works collaboratively with internal and external providers, physicians, and other health care disciplines to facilitate the referral management and clinical review process. Assists with post service utilization activities as requested by RMCR management. Essential Functions: - Makes clinical decisions and applies critical thinking to ensure continuity of care for inpatient and outpatient referrals by working collaboratively with internal and external health care professionals - Interprets and applies clinical information to make delivery decisions and determine appropriate level of care for utilization review activities - Conducts reviews of members in non-plan facilities and performs pre certification for inpatient skilled nursing services, LTAC, surgeries, and other admissions. Responsible for discharge planning and may assist with post service utilization activities - Serves as resource for referral specialists and other non-clinical regional staff such as customer relations and DME. Provides clinical guidance and benefit interpretation as it relates to clinical scenarios - Assists with research and interpretation of Medicare regulations and other pertinent regulatory requirements. Uses clinical knowledge to make appropriate decisions regarding request for service - Communicates with internal and external providers, vendors and health care staff to facilitate the RMCR management process Qualifications: Basic Qualifications: - 2 years experience in Referral Management or Clinical Review - Associate's degree in a related field - Current, active, and unrestricted license as a Registered Nurse in the State of Ohio - Strong computer skills including Microsoft Office, Diamond, Macess, Electronic Medical Record system (Epic, KP HealthConnect), Tapestry and BETS applications experience - Good analytical and problem solving skills Hours: Monday through Friday 8:00 a.m. to 5:00 p.m.