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Collect case specific member information, review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services. Review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care of delivery, and the need for planning subsequent care for contracted members and their eligible dependents as assigned. Providing clinical and managed care expertise, as well as Medical Director/physician consultation. Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Prospective Review Urgent/ Non-urgent, Concurrent Review, Retrospective Review, Early initiation of discharge coordination, Analyze case-specific patient information. Verify eligibility, as applicable, and past utilization history. Client-specific protocol and procedures Maximize referrals to network providers. Evaluation for referral to case management. Focused Second Surgical Opinion Review. Identifying and reporting quality of care issues. Answer telephone calls promptly as scheduled and as needed. Maintain working knowledge of all client groups Demonstrate adequate competence in computer software use in daily activities. Review case-specific patient information concurrently for the medical necessity of hospital admissions using commercial review criteria and/or scripted guidelines. Based on severity or complexity of the enrollee s condition, ability to meet commercial review criteria and or scripted guidelines, the necessary treatment, and the discharge planning activity. the nurse reviewer will assign the appropriate LOS days/ visits/ services in review of the clinical information obtained. Document pertinent clinical information regarding individual reviews designated format. Ensure timely notification of all parties (telephonic and/or written), as necessary, regarding certification recommendations. Assist in administering the second surgical opinion process. Handle caller requests addressed to other staff members; acts as a liaison assist the caller by routing to the appropriate person/ staff. Prepare case files for physician review via Physician Consultant Services or Medical director. This includes preparation of clinical information; correspondence. Function as a member of a self-directed team to meet specific individual and team performance metrics. Telephonic discussions with health care providers and members to explain medical appropriateness determinations and to obtain additional clinical information. Ensure consistent application of the utilization review process for all functional components. Document case review findings, actions, and outcomes in accordance with policy. Participate in special projects, as needed Participate in team meetings. Review clinical coverage reviews and assure client recommendations, as designated. Manage workload to ensure timely processing per state and federal mandates Estimated Duration: 3 Month Additional Information: Case Management Certification desired. Qualifications include: Active PN nurse licensure; minimum of 1 year clinical experience in an acute care setting Previous Utilization Management experience preferred, Sound clinical judgment, Demonstrated understanding of managed care concepts, Strong problem solving and decision making skills, Strong departmental team player, Good written and verbal communication skills, Personal computer skills, Strong time management and prioritization skills, Excellent customer service skills including a sense of urgency and ownership for resolving issues, Strong interpersonal skills at an individual and team level, Ability to be flexible, adjust quickly and react positively to change, Knowledge of ICD-9 and CP coding preferred, Considerable knowledge of principles, practices and current trends in nursing, Positive attitude and good work ethic.

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