Utilization Review Nurse-Piscataway, NJ – (17011528)Janet Rangi
The Utilization Review Nurse is responsible for ensuring the provisions for high quality medical care at an appropriate service level, in the most cost effective and appropriate setting, utilizing a defined network of providers. Reviews cases for potential need for case management or disease management and makes referrals. RNs work with oversight of an MD utilizing established screening criteria and within scope of licensure.
|Job Category||Healthcare, Nursing|
|Position||Utilization Review Nurse-Piscataway, NJ|
|Educational Qualifications||Active, unrestricted New Jersey RN License required Bachelor’s Degree strongly preferred|
|Professional Qualifications||Experience with Utilization Management/Concurrent Review experience in a managed care environment preferred Proficiency in MS Office (Word, Excel, Outlook) Excellent time management, organizational, research, analytical, customer service, communication (verbal and written) and interpersonal skills Ability to work in an automated environment Ability to function as part of a team|
|Previous Experience||A minimum of 3 years of clinical experience required, preferable in an acute setting|
|Responsibilities||• Provides service delivery on assigned products in a manner consistent with established standard policies/procedures and customer result expectations. Responsibilities include, but are not limited to, the following: • Work with providers and members to identify contracted providers for provision of services • Utilizes trigger list to identify cases which require case management and disease management services • Evaluates medical information against criteria, benefit plan, and medical policies and determines medical necessity for procedure and refers to Medical Director if criteria is not met • Adheres to quality assurance standards and all utilization management policies and procedures • Advises supervisor of any concerns or complaints expressed by providers or members • Attains established production standards and operational objectives including reviews/transactions completed per day, case documentation, and telephone response requirements • Compliant with all accreditation, state, and federal mandates • Participates in departmental and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate • Demonstrates sensitivity to culturally diverse situations, members, and clients • Maintains and sends hospital logs as assigned • Attends Concurrent Review meetings on a weekly basis • Utilizes effective communication, courtesy, and professionalism in all interactions, both internally and externally. Assists and supports other departments as required. • Attends all other team and departmental meetings upon request of the Supervisor, Manager, or Director of Care Management • Responsible for providing support to teammates as directed by Management • Complete Reinsurance notifications as per policy • Performs additional departmental duties below as appropriate: • Participates on special projects/client demonstrations • Supports and assists with training and precepting as required|