Clinical Care / Utilization Reviewer is responsible for processing medical necessity reviews for appropriateness of authorization for health care services retrospectively to verify the delivery of healthcare services happens in a cost effective manner.
Essential Functions:
- Complete retrospective review of acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
- Refer cases to Medical Directors when clinical criteria is not met or case conference is needed/appropriate
- Maintain knowledge of state and federal regulations and accreditation standards
- Perform any other job duties as requested
Education and Experience: Completion of an accredited licensed practical nursing (LPN) degree program is required / RN / Therapist
- Minimum of Eight (8) years of medical/surgical acute care or clinical experience required
- Minimum 7-8 years’ utilization review and/or case management experience required
- Experience with Medicaid, Medicare, Commercial and Managed Care preferred
Competencies, Knowledge and Skills: Basic data entry skills and internet utilization skills Knowledge of Microsoft Outlook, Word, Excel
- Communication Skills; written and verbal
- Ability to work independently and within a team environment
- Decision making/problem solving skills
- Experienced in using MCG / InterQual Guidelines
Licensure and Certification:
- Current, unrestricted LPN / RN/Therapist licensure is required
REQUIREMENT :
- IMMEDIATE FOR A TWO WEEK SPECIAL PROJECT TO DO UM REVIEWS
- PAY ABOVE MARKET RATE
- CAN GET CONVERTED INTO A FIT POSITION
Job Types: Part-time, Contract
Salary: $30.00 – $50.00 per hour
Schedule:
- Monday to Friday
Experience:
- Utilization review: 5 years (Preferred)
- Milliman Care Guideline: 3 years (Preferred)
License/Certification:
- RN / LPN / Therapist (Preferred)
Work Location: One location
Source: Indeed.com
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