Care Review Nurse Job

REGISTERED NURSE needed for a LONG TERM CONTRACT opportunity with Yoh's client located in Troy, Michigan.

TOP SKILLS YOU SHOULD POSSESS:

- Must be an RN with Utilization background in either Managed Care of Provider environment (at least two years) Experience with appeals highly preferred
- Interqual experience necessity!

WHAT YOU'LL BE DOING:

- Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care at the right place at the right time.
- Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Essential Functions:
- Provides concurrent review and prior authorizations (as needed) according to policy for members as part of the Utilization Management team.

WHAT YOU NEED TO BRING TO THE TABLE:

- Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care.
- Maintains department productivity and quality measures.
- Attends regular staff meetings. Assists with mentoring of new team members. Completes assigned work plan objectives and projects on a timely basis.
- In depth knowledge of Interqual and other references for length of stay and medical necessity determinations. Experience with NCQA.
- Ability to take initiative and see tasks to completion. Computer Literate (Microsoft Office Products).
- Excellent verbal and written communication skills.
- Preferably hospital nursing, utilization management, and/or case management. Required Licensure/Certification: Active, unrestricted State Nursing (RN) license in good standing.

GET HIRED, APPLY NOW!

RECRUITER: Jennifer Yerkes

Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer, M/F/D/V. Contact us if you are an individual with a disability and require accommodation in the application process.

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