Utilization Review Nurse: MCMC llc

Summary:

Broad based review of care plans and relevant clinical review criteria/ guidelines to determine necessity and appropriateness of care. Coordination of peer review, when no treatment guidelines or criteria are available. Phone support to providers, patients and health plans (as below). Thorough and detailed documentation of review process. Function as team member with other reviewers, support staff and peer reviewers. Participate in quality assurance reviews and committees.

Responsibilities:

• Respond to phone inquiries from providers, patients, case managers and accounts
• Thorough and detailed review of medical documentation and referencing of appropriate criteria/guidelines
• Determinations of medical necessity and appropriateness based on guidelines
• Coordination of peer reviews as necessary
• Thorough and detailed documentation of review process, findings and rationale for decisions
• Other duties as necessary

Qualifications:

Experience/Education

• Clinical background as practitioner
• Familiarity with personal computers as it relates to word processing and data input
• Good oral and written communication skills
• Ability to deliver quality customer service to providers, patients, and insurers