The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.
Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.
MAJOR DUTIES & RESPONSIBILITIES
- Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
- Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
- Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
- Input and manage essential clinical details within various medical management platforms.
- Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
- Apply clinical reasoning to determine the suitable evidence-based guidelines.
- Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.
Requirements
- Proficient in both written and spoken communication.
- Capable of maintaining professional communication with physicians and clients.
- Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting.
- Possesses a keen organizational sense and pays close attention to details.
- Adept at resolving intricate and multifaceted problems.
- Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
- Background in medical or clinical practice through education, training, or professional engagement.
- Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).
Additional Duties
- May provide oversight to the work of the team members.
- Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher