Utilization Review Nurse Job in Convington 70433, Louisiana Us
Description
MMO Behavioral Health Systems is in need of a Utilization Review Nurse (URN). Individuals would be responsible for providing a variety of services with respect to medical care authorization and delivery, cost containment, claims review, appeals and grievances and analytical reporting.
Duties and Responsibilities Include:
· Obtains and evaluates medical records for admission to determine if required documentation is needed
· Obtains appropriate records as required by payer agencies
· Identifies pay source problems and provides intervention for appropriate referrals
· Communication with hospitals, physicians and subscribers regarding certification of hospital admissions, outpatient services and post procedure follow up
· Educates the member about plan benefits and contracted physicians, facilities and healthcare providers
· Review patients' records and evaluates patient progress
· Reviews requests for medical treatment or procedures for appropriateness/quality of treatment and bill accordingly by group each month
· Conducts pre-certification, concurrent, retrospective, out of network and appropriate of treatment setting reviews with scope of licensure
· Performs utilization review in accordance with all state mandated regulations
· Answer questions from providers regarding reimbursement, prior authorization and documentation requirements.
· Other job duties as assigned Requirements:
Requirements
· Minimum of 2 years of clinical experience with at least 1 year of case management or utilization review experience
· Must have a current / valid license of Louisiana Registered Nurse
