Utilization Review Nurse

• Use established medical policy and guidelines to perform prospective, concurrent, and retrospective medical necessity review of post-acute care services to ensure medical necessity for appropriate setting, appropriate length of stay, including appeal requests initiated by providers, facilities and members. • Will coordinate care through the health care continuum including member outreach. • Provides support and alternative care support for members not appropriate for post-acute care service as well formulate discharge readiness for members transitioning from a post-acute care setting to a lower level of care. • Should have experience with InterQual.

Requirements

• Bachelor’s degree in nursing, allied health, business, or related field preferred. • Two to four years of clinical experience which may include post-acute care, home care, acute patient care, discharge planning, case management, and utilization review, and caring for aging population in the home or post-acute care setting, etc. • Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. • One year health insurance plan experience or managed care environment preferred. • Registered Nurse with current unrestricted Michigan Registered Nurse license required.