About the Role

• This position is part of the Utilization Management team, primarily responsible for conducting inpatient medical necessity and utilization reviews.
• The role focuses on ensuring that members receive the appropriate care at the right time and place.
• The position involves daily evaluations of members requiring hospitalization or procedures, providing prior authorizations, and conducting concurrent reviews.
• The goal is to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations.

Responsibilities

• Conduct concurrent reviews and provide prior authorizations as needed, following company policies.
• Determine appropriate benefits, eligibility, and expected length of stay for members requesting treatments or procedures.
• Collaborate with interdepartmental teams to enhance continuity of care, including Behavioral Health and Long Term Care.
• Maintain department productivity and quality standards.
• Participate in regular staff meetings and assist in mentoring new team members.
• Complete assigned work plan objectives and projects in a timely manner.
• Foster professional relationships with the provider community and internal/external customers. 
• Adhere to the company Code of Conduct and workplace safety standards.
• Consult with and refer cases to medical directors as necessary.

Education Qualification

• Completion of an accredited Registered Nursing program.
• A combination of experience and education may be considered in lieu of a Registered Nursing degree.

Required Skills

• Strong communication, problem-solving, and interpersonal skills.
• Excellent organizational skills with the ability to manage multiple priorities.
• Ability to work independently and handle multiple projects simultaneously.
• Knowledge of applicable state and federal regulations.
• In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA.
• Proficiency in MS Office Products.
• Excellent verbal and written communication skills.
• Ability to maintain confidentiality and comply with HIPAA regulations.
• Skilled at establishing and maintaining positive and effective work relationships.
• Required Experience
• Minimum of 0-2 years of clinical practice, preferably in hospital nursing, utilization management, and/or case management.
• Required Licensure/Certification
• Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.