Overall Purpose:
Responsible to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

RESPONSIBILITIES:
• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. 
• Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. 
• Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria. 
• Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes denial determinations. 
• Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract. 
• Consult with clinical reviewers and/or U.S.-licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process. 
• Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge planning. 
• Facilitate member care transition through the healthcare continuum and refer treatment 
plans/plan of care to clinical reviewers as required.
• Determine contract and benefit eligibility; obtain/confirm intake (demographic) information from callers and/or faxes.

OTHERS:    
Project Shift Schedule: Night shift
Project Rest Day: Weekends Off

Qualifications:

• Graduate of Bachelor’s degree in Nursing
• Must have at least 3 months clinical work experience
• Holds current and unrestricted US Registered Nurse license
• Excellent written and verbal communication skills in English

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