Clinical Care Reviewer - UM 8/10/2016

Della Infotech Inc. North Charleston, SC

Company
Della Infotech Inc.
Job Classification
Full Time
Company Ref #
28703863
AJE Ref #
575844229
Location
North Charleston, SC
Job Type
Regular

JOB DESCRIPTION

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JOB DESCRIPTION:

Current, unrestricted SC Registered Nurselicense.

3+ years' experience in critical care or ER within an acute care environment.

2+ years' experience in utilization management, preferably within managed care.

Comfortable utilizing MS Office products, including Excel, Word, and Outlook.

RESPONSIBILITIES:

Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse's discretion to pending requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.