Utilization Review Nurse - WFH

About This Gig

Job Purpose The Utilization Management Review Nurse reviews the medical necessity and appropriateness of healthcare services and treatments through the medical information of individual patients and the limited insurance coverage available to them. The Utilization Management Review Nurse works with healthcare providers, insurance companies, and patients to ensure the quality of patient care is cost efficient. Duties and Responsibilities Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures. Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits. Conducts initial benefit determination reviews. Consults with UM Medical Director to review requests that do not meet medical necessi

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