Utilization Review Nurse

Experience these exceptional benefits when you join Med-Metrix! 8-Hour Shifts Day 1 HMO with 2 of your dependents covered for FREE Group Life Insurance Medical Cash Allowance Rice Allowance Clothing Allowance Holiday Gift Bereavement Assistance Free Lunch Daily Paid Time Off Training and Staff Development Employee Engagement Activities Opportunities for Internal Mobility Job PurposeThe 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 necessity. Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Generates appropriate written correspondence to providers and/or members in accordance with UM policies and procedures. Adheres to company policies and procedures regarding confidentiality and privacy. Qualifications Must have valid PHRN License; USRN license is a plus. Minimum of 1 - 2years experience in Utilization Management. Experience utilizing UM criteria including MCG or InterQual. Minimum of three (2) years clinical nursing experience in an ambulatory or hospital setting. Proficient computer skills and experience with Microsoft web-based applications. Experience in managed care and health insurance required. Ability to communicate effectively English, both written and verbal. Ability to work holiday and weekend rotation. Working Conditions Work Set-Up: Hybrid Work Schedule: Night shift, US hours; PH holidays and weekend rotation. Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress. Work Environment: The noise level in the work environment is usually minimal.